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SESSION 1906-1907. 



19 7. ^>/ 



This, the thirty-second volume of the Society's Transactions, 
contains a record of its proceedings during the Session 1906-1907. 

In it, as in former volumes, the views brought forward in the 
Papers are to be considered as those of the writers themselves, 
and not as those of the Society as a body. 

The Editor. 

October 1907. 







WILLIAM CRAIG, M.D., F.R.C.S.Ed., 71 Bmntsfield Place. 

£ecrd aries. 
JAMES LAMOND LACKIE, M.D., F.R.C.P.Ed., 1 Randolph Crescent. 

50 Melville Street. 



12 Charlotte Square. 

Cbitor of ^Transactions. 
ANGUS MACDONALD, M.B., F.R.C.S.Ed., 27 Manor Place. 

$Vtcmbcrs of Council. 

Professor Sir JOHN HALLIDAY CROOM, M.D., F.R.C.S.Ed., 

F.R. C.P.Ed. 
SAMUEL SLOAN, M.D., F.F.P. & S.Glas., Glasgow. 

List of Presidents, Vice-Presidents, Treasurers, 
Secretaries, and Librarians of the Society. 




Dr William Beilby, . 


Sir A. R. Simpson, 


Sir James Y. Simpson, Bart. 


Dr John Connel 


Dr John Moir, . 


Sir J. Halliday Croom, 


Dr Alex. Keiller, 


Dr C. E. Underhill, . 


Dr T. H. Pattison, . 


Dr D. Berry Hart, 


Dr T. Graham Weir, . 


Sir A. R. Simpson, 


Sir James Y. Simpson, Bart. 


Dr A. H. Freeland Barbour, 


Dr John Burn, . 


Dr Alexander Ballantyne, 


Dr Charles Bell, . 


Sir J. Halliday Croom, 


Dr L. R. Thomson, 


Dr R. Milne Murray, . 


Dr Matthews Duncan, 


Dr James Ritchie, 


Sir A. R. Simpson, 


Dr N. T. Brewis, 


Dr David Wilson, 


Dr J. W. Ballantyne, . 


Dr Angus Macdonald, 


Sir J. Y. Simpson, Bart.. 
Dr Alex. Ziegler, 
Dr J. Cowan, R.K, 
Dr Fairbairn, 
Dr Charles Ransford, 
Dr R. B. Malcolm, 
Dr Charles Bell, . 
John Kennedy, Esq., 
Dr John Moir, . 
Dr T. H. Pattison, 
Dr Beilby, . 
Dr T. Graham Weir, 
Dr R. B. Malcolm, 
Dr John Moir, . 
Dr T. Graham Weir, 
Dr John Moir, 
Dr W. dimming, 
Dr A. Thomson, . 
Dr T. H. Pattison, 
Dr David Wilson, 
Dr T. Graham Weir, 
Dr George S. Keith, 
Dr T. Graham Weir, 
Dr Alex. Keiller, 
Dr T. H. Pattison, 
W. S. Carmichael, Esq. 
Dr John Burn. . 
Dr Charles Bell, . 
Dr William Bryce, 
Dr J. A. Sidey, . 
Dr William Menzies, 
Dr L. R. Thomson, 
Sir A. R. Simpson, 
Dr J. Matthews Duncan, 
Dr Angus Macdonald, 
Dr R. Peel Ritchie, . 


. Year. 


Dr James Young, 


Dr Alex. Milne, . 


Dr R. Peel Ritchie, . 


Dr Angus Macdonald, . 


Sir A. R. Simpson, 


Dr Robert Bruce, 


Dr James Carmichael, . 


Sir J. Halliday Croom, 


Dr Angus Macdonald, . 


Dr Charles E. Underhill, 


Dr William Ziegler, 


Sir A. R. Simpson, 


Dr Leith Napier, 


Dr D. Berry Hart, 


Dr James Foulis, 


Dr A. J. Sinclair, 


Sir A. R. Simpson, 


Dr Peter A. Young, . 


Dr John Playfair, 


Dr Freeland Barbour, . 


Dr A. Ballantyne, 


Dr James Ritchie, 


Sir J. Halliday Croom, 


Sir A. R. Simpson, 


Dr R. Milne Murray, . 


Dr N. T. Brewis, 


Dr J. W. Ballantyne, . 


Dr Samuel Macvie, 


Dr F. W. N. Haultain, 


Dr J. Haig Ferguson, . 


Sir A. R. Simpson, 


Professor J. A. C. Kynoch. . 


Sir J. Halliday Croom, 


Dr D. Berry Hart, 


Dr William Fordyce, . 







Dr Ransford, 

1840 to 1842 

Dr J. A. Sidey, . 

1859 to 1867 

Dr G. Paterson, . 

1842 to 1847 

Dr James Young, 

1867 to 1875 

Dr Cumming, 

1847 to 1854 

Dr William Craig, 


Dr Keiller, . 

1854 to 1859 




Dr Ransford, 

1840 to 1842 

Dr Alexander Milne, . 

1873 to 1875 

Dr G. Paterson, . 

1840 to 1847 

Dr C. E. Underhill, . 

1875 to 1879 

Dr Dunsmure, 

1842 to 1847 

Dr James Carmichael, , 

1875 to 1881 

Dr Cumming, 

1847 to 1854 

Dr D. Berry Hart, 

1879 to 1883 

Dr Keith, . 

1847 to 1849 

Dr A. H. Freeland Barbour, 

1881 to 1886 

Dr J. M. Duncan, 

1849 to 1852 

Dr R. Milne Murray, . 

1883 to 1889 

Dr Keiller, . 

1852 to 1859 

Dr N. T. Brewis, . 

1886 to 1893 

Dr J. A. Sidey, . 

1854 to 1861 

Dr J. W. Ballantyne, . 

1889 to 1896 

Dr A. R. Simpson, 

1859 to 1865 

Dr F. W. N. Hauitain, 

1893 to 1897 

Dr Peter Young, . 

1861 to 1863 

Dr J. Haig Ferguson, . 

1896 to 1901 

Dr W. Stephenson, 

1863 to 1867 

Dr William Fordyce, . 

1897 to 1904 

Dr R. Peel Ritchie, 

1865 to 1873 

Dr Lamond Lackie, 


Dr G. Stevenson Smith, 

1867 to 1871 

Dr Barbour Simpson, . 


Dr James Andrew, 

1871 to 1875 




Dr J. Jamieson, . 

1875 to 1879 

Dr R. Milne Murray, . 

1889 to 1899 

Dr C. E. Underhill, . 

1879 to 1883 

DrF. W. N. Hauitain, 


Dr Peter Young, . 

1883 to 1889 




Dr J. W Ballantyne, . 

1896 to 1*99 

Dr J. Lamond Lackie, . 

1901 to 1905 

Dr N. T. Brewis, 

1899 to 1901 

Dr Angus Macdonald, . 






1898 Atthill, Lombe, M.D., Monkstown 
Castle, Co. Dublin. 

1897 Bantock, Dr George Granville, 14 
Upper Hamilton Terrace, Lon- 
don, N.W. 

1901 Bar, Prof. Paul, M.D., Rue la 
Boetie, 122, Paris. 

1906 Bossi.. Professor L. M., The 
University, Genoa. 

1886 Bozeman, Dr Nathan, 296 Fifth 
Avenue, New York. 

1901 Chrobak, Professor R., University of 

1898 Coe, Prof. Henry C, M.D., 27 East 

Sixty-fourth St., New York. 
1898 Cullingworth, Charles J., M.D., 

D.C.L., 14 Manchester Square, 

London, W. 
1898 Doyen, E., M.D., LL.D., Rue 

Piccini, 6, Paris. 
1882 Emmet, Dr, 93 Madison Avenue, 

New York. 

* Previous to 1861 the office of Treasurer was conjoined with that of Senior Secretary. 



1900 Fehling, Professor Herman, M.D., 1 1901 

Kaiser Wilhelm's University, 
1882 Freund, Emeritus Professor W., 1 1902 
Kleiststrasse, 5, Berlin. 

1901 Fritsch, Prof. H., University of 1895 


1902 Garrigues, Prof. H. J., Tryon, North 1898 


1891 Gusserow, Prof., Charite, Berlin. 1903 
1882 Hegar, Professor, Albert Ludwig's 

University, Frieburg. 1882 

1898 Kelly, Prof. Howard A., M.D., 

Johns Hopkins Hospital, Balti- 1903 
more, U.S.A. 
1907 Kinoshita, Dr Seichu, Professor of 1906 
Obstetrics and Gynaecology, Im- 
perial University, Tokio, Japan. 1905 

1892 Koeberle, Dr Eugene, Strassburg. 
1898 Leopold, Prof. G., M.D., Seminar 

Strasse, 25, Dresden. 1901 

1906 Makieyeff, Professor Alexander 

Matvejevic, The University, | 1876 

1895 Martin, Prof. Dr A., N. Greifs- 

wald. 1905 

1903 Morisani, Professor O., San Felice 1897 

a Piazza Dante, 10, Naples. 
1892 Miiller, Professor Peter, Berne 

1889 Olshausen, Professor, Frauenklinik 

Artillerie Strasse, 13, Berlin. 

Ott, Professor D. von, M.D., Pro- 
fessor of Obstetrics, University 
of St Petersburg. 

Pestalozza, Professor, Instituts 
Obstetrico Policlinico, Roma. 

Pinard, Professor A., Rue Cam- 
baceres, 10, Paris. 

Pozzi, ProfessorS., M.D., Hopital 
Broca, Paris. 

Schauta, Professor, Kochgasse, 16, 

Schultze, Professor B. S., Univer- 
sity, Jena. 

Segond, Dr Paul, Quai d'Orsay, 

Simpson, Emeritus Prof. Sir Alex. 
R., LL.D., 52 Queen St. 

Sinclair, Prof. Sir William Japp, 
Garvock House, Dudley Road, 

Sneguireff, Professor W., University 
of Moscow. 

Turner, Principal Sir W., K.C.B., 
LL.D., D.C.L., 6 Eton Terrace, 

Veit, Professor, University, Halle. 

Williams, Sir John, Bart., M.D., 
LL.D., Plas Llanstephan, Car- 

Winckel, Prof. Von, Ludwig-Maxi- 
milian's University, Munich. 

Zweifel, Professor, Frauenklinik 
University, Leipzig. 


1884 Arnott, Brig. Surg. -Lieut. -Col. Jas., 
8 Rothesay Place. 

1887 Baumgartner, Dr H. S., Newcastle- 

1892 Beilby, Dr J. H., Bromsgrove. 
1863 Belgrave, Dr, Sydney. 

1888 Bentley, Dr Arthur J., Cairo. 
1880 Bosch, Dr Van Den, Liege. 
1880 Brock, Dr W. J., Edinburgh. 

1863 Brown, Dr R. C, Preston. 

1887 Chepmell, Dr C. W. J., London. 
1894 Curatulo, Prof. G. E., Rome. 

1869 Davies, Mr Thos., Manchester. 
1873 Donovan, MrW., Birmingham. 

1877 Engelmann, Dr G., Kreuznach. 
1896 Eyres, Hugh, Richmond. 

1864 Finlay, Right Hon. Sir R. B., M.D , 

LL.D., K.C., London. 

1883 Fraser, Dr Dyce, London. 

1892 Fraser, Dr Hugh E., Dundee. 

1879 Glaister, Prof., Glasgow. 
1877 Grassett, Dr F., Toronto. 

1868 Grenser, Dr Paul W. T., Dresden. 

1864 Greve, Dr, Norway. 

1875 Groesbeck, Dr Hermann J., New 

1897 Gunsberg, Charkow, Russia. 

1853 Hall, Dr D., Montreal. 

1870 Haynes, Dr Stanley L., Malvern. 

1880 Helme, Dr J. M., Carnforth. 
1885 Helme, Dr T. A., Manchester. 

1865 Henderson, Dr E., China. 

1893 Howard-Jones, Dr J., Newport. 
1887 Hume, Dr T., Surgeon-Major, India. 

1881 Hurst, Dr George, Australia. 

1882 Husband, Dr H. Aubrey, Manitoba. 

1893 Hutchison, Dr Robert, London. 

1894 Jennings, Dr David D., New York. 


1871 Johnston, Dr A. C, R.N., London. 

1882 Johnston, Sur.-Maj. Wilson, India. 

1845 Keith, Dr George S., Currie. 
1867 Kingston, Dr, Montreal. 
1874 Kleinwachter, Prof. L., Gratz. 

1871 Lambert, Dr, Paris. 

1887 Limont, Dr J., Newcastle-on-Tyne. 

1867 Lord, Dr Richard, London. 

1878 Macdougall, Dr John A., Cannes. 

1879 Machattie, Dr Thomas A., Australia. 
1862 Mackay, Dr M. A., Canada. 

1870 M'Kendrick, Prof., Stonehaven. 
1869 M'Millan, Dr T. L., Australia. 
1879 Marshall. Dr Thomas, London. 
1866 Martin, Dr Karl, Berlin. 

1860 Milburn, Dr George, London. 

1883 Mills, Dr B. Langley, India. 
1897 Minchin, Dr, Charkow, Russia. 

1861 Mitchell, Sir Arthur, LL.D., Edin- 

1877 Moolman, Dr Henry, South Africa. 
1869 Mossop, Mr Isaac, Bradford. 

1884 Neve, Dr E. F., Kashmir. 
1849 Norris, Mr H., Petherton. 

1857 Parker, Dr, Nova Scotia. 

1869 Paton, Dr J. W., Bath. 

1885 Puckle, Dr S. Hale, Bishop's Castle. 

1880 Reid, Dr James More, Aldershot. 

1878 Serdukoff, Dr A., St Petersburg. 

1887 Shiels, Dr G. F., San Francisco. 

1870 Smith, Dr D., Montrose. 
1890 Smith, Dr William, America. 
1861 Stephenson, Prof. W., Aberdeen. 

1888 Stevenson, Sir Edmond Sinclair, 

Cape of Good Hope. 
1854 Storer, Dr H., Boston, U.S.A. 
1875 Sutugin, Dr V., St Petersburg. 

1867 Thomson, Mr W., Wrenbury. 
1880 Turner, Dr William, Gibraltar. 

1885 Underhill, Dr F. T., Vancouver. 
1861 Veale, Dr H. R. L., London. 

1864 Whiteford, Dr James, Greenock. 

1886 Whitton, Dr A. B., Aberchirder. 

1865 Wollowicz, Dr C, St Peters- 




Note.— Those marked with an asterisk have been Members of Council. Members of Council 
continue in office two years. 

Date of 





15 * 

Thomas John Fordyce Messer, M.D., F.F.P. & S. Glasg., 
Garelochhead, ...... 

John Charles O^ilvie Will, M.D., CM., Aberdeen, . 

William Spalding. M.D., M.R.C.S. Eng., Gorebridge, . 

George Dickson, M.D., F.R. C.S. Ed., . 
♦James Andrew, M.D., F.R.C.P. Ed., . 
*William Taylor, M.D., F.R.C.P. Ed., . 

James Ormiston Affleck, M.D., F.R. C.S. Ed., F.R.C.P. Ed., . 

William Craig, M.D., F.R, C.S. Ed., . 
'♦Professor Sir John Halliday Croom, M.D., F.R.C.S. Ed., 

F.R.C.P. Ed., 

'♦Alexander Ballantyne, M.D., F.R.C.P. Ed., Dalkeith, 

William Borwick Robertson, M.D., L.R.C.S. Ed., London, . 
'♦James Carmichael, M.D., F.R.C.P. Ed., 
'*Peter Alexander Young, M.D., F.R.C.P. Ed., . 
'♦Charles Edward Underhill, M.B., P.R.C.P. Ed., F.R.C.S. Ed., 
'♦John Play fair, M.D., F.R.C.P. Ed., Hon. F.R. C.S. Ed., 
'♦Henry Macdonald Church, M.D., F.R.C.P. Ed., 

James Lindsay Howison Herbert Porteous, M.D., F.R.C.S. Ed., 
M.R. C.P.Ed., New York . 



Archibald Bleloch, M.B., Sc.D., 

Joshua John Cox, M.D., F.R.C.S. Ed., Eccles, Manchester, 

20 *Thomas Rutherford Ronaldson, M.B., F.R.C.P. Ed., . 

Charles H. Thatcher, F.R.C.S. Ed., . 

*John Brown Buist, M.D., F.R.C.P. Ed., 

George Herbert Bentley, L.R.C.P. & S.Ed., Kirkliston, 

Andrew Douglas Ramsay Thomson, F.R.C.P. Ed., Musselburgh 

25 James Stitt Thomson, M.D., F.R.C.P.Ed., F.R.C.S. Ed., 

Lincoln, ...... 

John Archibald, M.D., F.R.C.S. Ed., Bournemouth, . 
*****David Berry Hart, M.D., F.R.C.P. Ed., 
♦David Menzies, M.B., F.R.C.S. Ed., . 
Donald Roderick Morrison Murray, M.B., CM., Leith, 
30 Robert Spence, M.B., CM., Burntisland, • . 

George Mackay, M.B., F.RCS. Ed., . 
James Henry Croudace, L.R.C.P. & S. Ed., Stafford, . 
Alexander Dinsey Leith Napier, M.D., M.R. C.P.L., Australia 
John M'Watt, M.B., CM., Duns, 
35 * William Nicol Elder, M.D., L.R.C.P. & S. Ed., 

Henry Hay, M.B., CM., .... 

Abraham Wallace, M.D., F.F.P. & S. Glasg., London, 
*John Rogerson Hamilton, M.D., CM., Hawick, 
George Roth well Adam, M.D., CM., Melbourne, 
40*****Alexander Hugh Freeland Barbour, M.D., F.R.C.P. Ed., 
James Murray, M.B., CM., . . . 

Andrew James Duncan, M.D., L.R.CS. Ed., Dundee, 
T. Edgar Underhill, M.D., F.R.C.S. Ed., Barnt Green, 
♦* William Loudon Reid M.D., F.F.P. & S. Glasg., Glasgow, 
45 ****James Ritchie, M.D., F.R.C.S. Ed., F.R.C.P. Ed., . 
William Alexander Finlay, M.D., F.R.C.S. Ed., Trinity, 
James More, M.D., M.R.C.S. Eng., Rothwell, Kettering, 
Thomas Rennie Scott, M.D., CM.. Musselburgh, 
♦George Hunter, M.D., F.R.C.S. Ed., F.R.C.P. Ed., . 
50 John E. Ranking, M.D., F.R.C.P.L., M.R.C.S. Eng., Tun 

bridge Wells, ..... 

♦Arthur Douglas Webster, M.D., F.R.C.P. Ed., . 
William Haig Brodie, M.D., F.R.C.S. Eng., M.R.CP.Lon. 
London, ...... 

James Hewetson, M.B., CM., Hohnfield, Reigate, 
♦♦Samuel MacYie, M.B.. CM.. Chirnside, 
55 John Waugh, M.D., CM., London, 

Hugh Logan Calder, M.D., F.F.P. k S. Glasg., 
Henry Anderson Peddie, M.B., CM., . 

Thomas Fisher Gilmour, L.R.C.P. Ed.,L F.P. & S. Glasg. , Lslay 
Andrew Stark Carrie, M.D., M.R.C.S. Eng., London, . 
60 William Black Alexander, L.F.P. & S. Glasg., 

Harry George Deverell, M.D., CM., . 
♦George Keppie Paterson, M.B., F.R.C.P.Ed., . 
Herbert R. Rendell, M.B., CM., St John's, Newfoundland, 
David Smart, M.B., CM., Liverpool, . 
65 ♦♦♦Nathaniel Thomas Brewis, M.B., F.R.C.P. Ed., F.R.C.S. Ed 
*John William Ballantvne, M.D., F.R.C.P. Ed., 
Thomas Proudfoot, M.B., F.R.C.P. Ed., 
W. Fraser Macdonald, M. B., CM., Glasgow, . 
William Spence, M.B., CM., Dollar, . 
70 William Wright Millard, M.B., CM., 

John Mowat, M.D., CM., 

James Lumsden Bell, M.B., CM., Driffield, Yorkshire, 
*Thomas Brown Darling, M.D., CM., . , , 

Date of 






*Harry Melville Dunlop, M.D., F.R.C.P. Ed., . 
75 * Robert William Felkin, M.D., London. 

James K. King, M.D., Watkins, New York, . 

William Marshall, L.R.C.S. Ed., Milnathort, . 

Fourness Barrington, M.B., F.R.C.S. Eng., Sydney, Australia 
•Francis William Nicol Haul tain, M.D., F.R.C.P. Ed., 
80 *John Struthers Stewart, L.K.C. P. & S.Ed., . 

Frederick Anastasius Saunders, F.R.C.S. Ed., L.R.C.P. Ed. 
Grahamstown, South Africa, 

John Smith, M.D., M.R.C.S. Eng., Kirkcaldy, 

William Gayton, M.D., M.R.C.P.L., M.R.C.S. Eng., London 

Gustave Michael, M. B., CM., London, . 
85 ** James Haig Ferguson, M.D., F.R.C.P. Ed., M.R.C.S. Eng. 
F.R.C.S. Ed., ..... 

John Edward Gemmell, M.B., CM., Liverpool, 

Robert Stewart, M.B., CM., . . . 

Surgeon-Captain Robert Charles Macwatt, M.B., B.Sc, CM. 
7th Bengal Cavalry, Bombay 
*E. H. Lawrence Oliphant, M.D., CM., Glasgow, 
90 James Hogarth Pringle, M.B., F.R.C.S. Eng., Glasgow, 

John Walton Hamp, L. F. P. & S. Glasg., L.S. A. , Wolverhampton 

James Auriol Armitage, M. D. , C M. , Wolverhampton, 

William Henry Miller, M.D., F.R.C.P. Ed., . 

John M'Call, L.R.C.P. Ed., Portobello, 
95 *Thomas Wood, M.D., CM., .... 

Hugh M'Callum, L.R.C.P. &S. Ed., Kinloch-Rannoch, 

Nutting Stuart Fraser, M.B., M.R.C.S. Eng., St John's, New 
foundland, ...... 

Augustus Alexander Matheson, M.D., F.R.C.P. Ed., . 

Robert Mackenzie, M.D., CM., Nairn, 
100 Thomas Jackson Thyne, M.B., F.R.C.P. Ed., . 

Ernest T. Roberton, M.D., M.R.C.S. Eng., New Zealand, 
•Samuel Sloan, M.D., F.F.P. & S. Glasg., Glasgow, 

James Wm. Fox, L.R.C.P. &S. Ed., Southampton, 

John Frederick Sturrock, M.B., CM., Broughty -Ferry, 
105 Alexander Primrose, M.B., M.R.C.S. Eng., Toronto, Canada, 

Arthur Per igal, M.D., M.R.C.S. Eng., New Barnet, Herts, 

James Aitken Clark, M.B., CM., 

Edward Carmichael, M.D., F.R.C P. Ed., 

Charles Clark Teacher, M.B., CM., North Berwick . 
110 Robert Inch, M.B., CM., Gorebridge, . 

Ellis Thomas Davies, M.D., M.R.C.S. Eng., Liverpool, 

John Orr, M.B., CM., Eccles, Lancashire, 
•George Owen Carr Mackness, M.D., CM., Broughty -Ferry, 

Francis Joseph Baildon, M.B., CM., Sotcthport, 
115 Surgeon-Lt. Ralph H. Maddox, M.B., M.R.C.S. Eng., I.M.S 
Bengal, ...... 

James Williamson Martin, M.D., F.R.C.P. Ed., Dumfries, 

James Andrew Blair, M.D., CM., D.Sc, Newcastle-on-Tyne, 
•John Thomson, M.D., F.R.C.P. Ed., . 

Robert Kirk, M.D., F.R.C.S. Ed., Bathgate, . 
120 * William Fraser Wright, M.B., CM., Leith, . 

Richard Joseph Tristan, L.R.C.P. & S. Ed., Retford, Notts, 

Robert Henry Blaikie, M.D., F.R.C.S. Ed., . 

James Hutcheson, M.D., F.R.C.S. Ed., . 

A. A. Jervis Pereira, M.D., Delag^a Bay, 
125 Christopher Martin, M.B., F.R.C.S. Eng., Birmingham 

John George Havelock, M.D., CM., Montrose, 

JohnPirie, M.B., CM. 

Date of 



















James Gibson Graham, M.B., CM., Glasgow, . 

Robert Adams Brewis, M.D., CM., Dursley, . 

John Allison, M.D., CM., Kettering, Northampton, . 

Archibald Cowan Guthrie, M.B., CM., 

Samuel Beatty, M.B., CM., Pitlochry, 

Professor James Chalmers Cameron, M.D., Montreal, . 

Albert Edward Morison, M.B., F.R.CS. Ed., M.R.CS. Eng. 

West Hartlepool, ..... 
George H. Temple, M.B., CM., Weston-super-Mare, . 
Norman L. Boxill, M.B., CM., Barbados, 
John Hunter Helm, M.B., CM., Jiatho, 
George Scott MacGregor, M.D., CM., Glasgow, 
William Sneddon, M.B., CM., Cupar-Fife, . 
Thomas Watts Eden, M.B., CM., London, 

* William Fordyce, M.D., F.R.CP. Ed., 

Charles E. Harvey, M.B., M.R.CS. Eng., Sav-la-Mar 
Jamaica, . ... 

Alexander Lang Murray, L.R.CP. & S. Ed., Australia, 
*GeorgePirrie Boddie, M.B., CM., . . 

James F. W. Ross, M. 1)., Toronto, Canada, 
Hugh Jamieson, M.D., CM., .... 

Thomas Wm. Nassau Greene, L.R.CP. Ed., L.R.CS.I 
Dublin, ...... 

Prof. John Clarence Webster, M.D., F.R.CP. Ed., Chicago, 

* William George Aitchison Robertson, M.D., F.R.CP. Ed., 
William Basil Orr, M.D., CM., 

* Edward Farr Armour, M.B., CM., . 
George Wilkinson, M.D., CM., Liverpool, 

* James Lamond Lackie, M.D., F.R.CP. Ed., . 
James Wilson, M.B., C.M., .... 
Archibald Maclean, M.D., CM., Kilmarnock, 
Frederick William Lyle, M.D., CM., London, 
Thomas Dobson Poole, M.D., CM., Liuthwaite, 
Charles Newberry Cobbett, M.D., CM., Alberta, 
Alexander William Gordon Price, M.B., CM., 

Hugh Shapter Robinson, M.R.CS. Eng., L.R.CP. Ed., London 
*George Matheson Cullen, M.D., CM., 

Frederick Albert L. Lockhart, M.B., CM., Montreal, Canada 

Edmund Frederick Tanney Price, M.B., CM., 

Ernest Theophilus Roberts, M.D., CM., Keighley, 

Owen Foulkes Evans, M.D., CM., Liverpool, . 

James Duncan Farquharson, M.B., CM., Newcastle- on- Tyne, 

Harvey Littlejohn, M.B., F.R.CS. Ed., 

Robert Wise, M.D., CM., London, 

William Russell, M.D., F.R.CP. Ed., 

Alexander Scott Duncan, M.B., CM., Polton, 

Prof. William Keiller, F.R.CS. Ed., Galveston, Texas, U.S. A 
*Michael Dewar, M.D., CM., . 

Gains T. Smith, M.D., Moncton, New Brunswick, 

John Hugh Alexander Laing, M.B., CM., 

Robert Thin, M.B., F.R.CP. Ed., 

Alexander Henry Vassie, M. B., CM., London, 

James Harvey, M.D., CM., 

Alexander Henderson, M.B., CM., 

James Smith, M.D., CM., 

George Balfour Marshall, M.D., CM., Glasgow, 

William Booth, F.R.CS. Ed., . 

Richard T. Yoe, M.D., Louisville, Kentucky, U.S.A., 

Alexander Bruce Giles, M.D., CM.. 

Date of 






Hamilton Graham Langwill, M.D., F.K.C.P. Ed., Leith, 

185 Herbert Ernest Lee, M.B., CM., Australia, 

Charles Martin, M.B., CM., Newton A bbot, . 
William Murray Cairns, M.B., CM., Liverpool, 
Robert Dundas Helm, M.D., CM., Carlisle, . 
James Thomas Moore Giffen, F.R.C.S. Ed., Chester, . 

190 Frank Dendle, M.B., D.P.H., Islcworth, 

Frederick Thomas Anderson, M.D., F.R.C.S. Ed., 

Simson Carstairs Fowler, M. B., CM., Juniper Green, 

Prof. John Alexander Campbell Kynoch, M.B., F.R.C.P. Ed. 

Dundee, . 
Walter John Shaw, M.B., CM., Cockburnspath, 

195 Robert Stirling, M.D., CM., Perth, . 

William Henry Vickery, F.R.C.S. Eng., L.R.C.P. Lond. 

Weston-super-Mare .... 

William Ramsay Smith, M.B., CM., Australia, 
Charles Frederick Ponder, M.D., CM., Tasmania, 
John Tod, M.B., CM., Leith, . 

200 George Henry Walter Smith, M.D., CM., Sydney, Australia 
Charles Croomhall Easterbrook, M.D., CM., Ayr, 
Walter Petrie Simpson, M. B., CM., Bathgate, 
*James Ernest Moorhouse, M.D., CM., Stirling, 
D. W. Johnston, F.R.C.S. Ed., Johannesburg, South Africa, 

205 David George Davidson, M.B., CM., . 

Allen Thomson Sloan, M.D., CM., . 
Robert Balfour Graham, F.R.C.S. Ed., 
Albert Frederic Rosa, M.D., CM., 
George Benjamin Mitchell, M.B., CM, 

210 Henry Robins, M.D., Jamaica, 

Linn J. Schotield, M.D., Warrensburg 

George Morton Wilcockson, L.R.C.P. & S. Ed., Reading 

John MacRae, M.D., CM., Murray field, 

George Wade, M.D., CM., Melrose, . 

215 Philip Grierson Borrowman, M.D. , CM., Crieff] 

William Herbert Gregory, M.D., CM., Beverley, Forks, 
James Gibson Cattanach, M.B., F.R.C.P. Ed., 
Alexander Maitland Easterbrook, M.B., CM., Gorebridge, 
Robert William Roberts, L.R.C.P. & S. Ed., North Wales, 

220 Claude Buchanan Ker, M.D., F.R.C.P. Ed., . 
Charles Alexander Butchart, M.B., CM., 
Frederick Maurice Graham, F.R.C.S. Ed., L.R.C.P. Ed., 
Robert Hoggan, M.B., CM., Liberton, 
James Livingstone Thompson, M. B., CM., Australia, 

225 John Stevens, M.D., F.R.C.P. Ed., . 

Hugh Lewis Hughes, L.R.C.P. & S. Ed., Dowlais, 
Sylvaniis Glanville Morris, M.D., CM., Mardy, 
Thomas Easton, M.D., CM., Southampton, 
David Robertson Dobie, M.D., CM., Crieff, . 

230 Gopal Govind Vatve, M.D., Bombay, . 

Robert William Beesley, M.D., CM., Bolton, . 
William A. Stephen, M.D., CM., Loftus -in- Cleveland, 
William Edward Fothergill, M.D., CM., Manchester, 
George Sandi son Brock, M.D., CM., Rome. 

235 *John Martin Munro Kerr. M.B., CM 

John Montgomery, M.B., CM., Birmingham, 
*Robert Cochrane Buist, M.D., CM., Dundee, . 
Robert Thomson Ferguson, M.B., CM., Anstruther, 
Angus Vallance MacGregor, M.D., CM., West Hartlepool, 

240 Charles William Donald, M.D., F.R.C.S. Ed., Carlisle, 

Leven, Fife, . 

, Whitby, 

! Mo., U.S.A., '. 

Date of 














Date of 

John Strutbers, M.B., CM., TransJcei, South Africa, . 1895 

B. W. Broad, M.B., CM., Cardiff, .... 1895 

Edwin Hindmarsh, M.B., CM., 'Bengal, . . 1895 

Patrick Mackin, M.D., F.R.CS. Ed., New Zealand, . . 1895 

G. Edgar Helme, M.B., CM., Manchester, . . . 1895 

Percy Theodore Hughes, M.B., CM., Broomsgrove, . . 1895 

John Hosack Fraser, M.B., F.R.CP. Ed., Bridge of Allan, . 1895 

Stewart Grant Ogilvy, M.B., CM., Fauldhouse, . . 1895 

Thomas Howard Morgan, M. D., F.R.CS. Ed., Queensland, Aust., 1895 

William Macrae Taylor, M.B., F.R.CS. Ed., . . . 1895 

David James Graham, M.D., F.R.CP. Ed., . . 1895 

Walter William Chipman, M.D., F.R.CS. Ed., Montreal, . 1895 

John dimming, M.D., F.R.CS. Ed., F.R.CP. Ed., . . 1896 

Sol Jervois Aarons, M.D., CM., London, ... . 1896 

Robert Beveridge, M.B., CM., Leith, . . . 1896 

John Anderson, M.B., CM., Pitlochry, . . . 1896 

Thomas John Burton, M.D., CM., Australia, . . 1896 

Robert Gordon M'Kerron, M.B., CM., Aberdeen, . . 1896 

Frederick John M'Cann, M.D., M.R.C.P.L., London, . 1896 

David Robert Taylor, L.R.C P. & S.Ed., Ayton, . . 1896 

George William Simla Paterson, M.B., CM., . . . 1896 

Robert Henry Watson, M.D., CM., Hamilton, . . 1896 

Thomas Marshall Callender, M.D., CM., Sidcup, . . 1896 

Lewis Grant, M.D., CM., Neston, .... 1896 

Robert Robertson, M.B., CM., . .... 1897 

James Wilkie, L.R.C P. & S. Ed., Portobello, ... 1897 

Andrew Graham, M.D., Currie, .... 1897 

Roderick Murdoch Matheson, M.D., F.R.CS. Ed., . . 1897 

*Robert Jardine, M.D., F.F.P.S. Glasg., M.R.CS. Eng., 

Glasgow, . . . . . . . 1897 

Daniel Charles Edington, M.D. , CM., Penrith, . . 1897 

John Macmillan, M.D., F.R.CP. Ed., F.R.CS. Ed., . . 1897 

Harold Sherman Ballantyne, M.B., CM., Dalkeith, . . 1897 

Ernest Edward Porritt, M.D., F.R.CS. Ed., New Zealand, . 1897 

William John Garbutt, M.B., CM., Birmingham, . . 1897 

Henry John Forbes Simson, M.B., F.R.CS. Ed., London, . 1897 

William Alexander Potts, M.D., CM., Birmingham, . . 1897 

Angus Macdonald, M.B., F.R.CS. Ed., . . . 1897 

Bernard Samuel Story, M.D., F.R.CS. Ed., New Zealand, . 1898 

Alexander Macdonald, M.B., F.R.CS. Ed., | . . . 1898 

George Robert Livingston, M.D., CM., Dumfries, . . 1898 

Charles Carmichael Forrester, M.B., CM., . . . 1898 

William Morrison Milne, M.B., CM., . . . . 1898 

William Joseph Murphy Barry, M.D., M.R.CP.Ed., 

Penarth, . . . . . . . 1898 

John Christie Forbes, L.R.C. P. & S. Ed., Liberton, . . 1898 

Alexander Cruikshank Ainslie, M.D.. CM., . . . 1898 

Henry Aylmer Dumat, M.D., F.R. C.P.Ed., Durban, South 

Africa, . . . . . . . 1898 

Gabriel Maurange, M.D., Paris, .... 1898 

John Thomas Woodside, L.R.C. P. & S. Ed., Stewartstown, . 1898 
George Freeland Barbour Simpson, M.D., F.R.CS. Ed., 

F.R.CP. Ed., 1898 

Alfred Charles Sandstein, M.D., Ch.B., New Zealand, . 1898 

Alfred Shearer, M.B., Ch.B., Newtown, N. Wales, . . 1898 

John Henry Rhodes, M.B., Ch.B., Kendal, . . . 1898 

James Duncan Slight, M.D., Ch.B., Leicester, . . . 1898 

Francis John Harvey Bateman, M.D., CM., London, . . 1898 

Robert John Johnston, M.B., CM., . . . . 1899 


List of fellows. 

William Bertie Mackay, M. D. , Berivkk-on- Tweed, 

Edward William Scott Carmicliael, M.D., F.R.C.S. Ed.. 

James Wilson M'Brearty, F.R.C.S. Ed., L.R.CP. Ed., New 
Zealand, ...... 

George Crewdson Thomas, M.D., CM., London, 
300 John Eason, M.D., F.R. C.P.Ed., Leith, 

William John Barclay, M.D., F.R.C.S., Ed., New Zealand, 

Frederick Adolphns Fleming Barnardo, M.B., Ch.B., India, 

Alexander Dingvvell Fordyce, M.D., F.R.C.P. Ed., . 

William Thomas Ritchie, M.D., F.R.C.P. Ed., 
305 Owen, St John Moses, M.D., CM., B.Sc, Calcutta, . 

Charles Wakeham Holmested, L.R.CP. & S. Ed., L.F.P.S 
Glasg., Tuxford, ..... 

Donald MacGregor, M.D., CM., Jedburgh, 
*Harry Oliphant Nicholson, M.D., F.R.C.P. Ed., 

Thomas Scott Brodie, M. B., CM., Wishaw, . 
310 William Hope Fowler, M.B., Ch.B., . 

John Stanley Manford, M.B., B.S., Neivcastle-on-Tyne, 

Ogden Watson Ogden, M.D., M.R.C.S., Newcastle-on-Tyne, 

John Craig, M.B., Ch.B., .... 

William Hartley Bunting, M.D., F.R.C.S. Ed., Birmingham, 
315 Theodore Charles Mackenzie, M.B., Ch.B., Aberdeen, . 

Donald George Hall, M.B., M.R.C.S. Eng., Sussex, . 

Hugh Corbett Taylor Young, M.D., CM., Sydney, 

John Boyd Jamieson, M.D., F.R.C.S. Ed., 

Malcolm M'Larty, M.B., CM., 
320 Peter Joseph Henry Ferguson, M.B., CM., 

Frederick Gardiner, M.D., CM., 

George Mackie, M. B., Ch.B., Malvern, 

Kenmure Duncan Melville, M.D., Ch.B., 

John Thomas Dickie, L. R. C P. & S. Ed. , 
325 William Ernest Frcst, M.B., Ch.B., . 

Frederick David Simpson, M.D., F.R.C.S. Ed., 

Francis Wilfrid Harlin, F.R.C.S. Ed., L.R.CP. Ed., Queens- 
land, ...... 

William Darling, M.B., F.R.C.S. Ed., 

Robert Macfarlane Mitchell, M. B., F.R.C.S. Ed., Australia, 
330 Malcolm Campbell, M.B., F.R.C.S. Ed., 

James Ramsay Munro, M. D. , Ch.B., Spalding, 

George James Rogerson Carruthers, M.B., Ch.B., 

Hilda Maud M'Farlane, L.R.CP. & S. Ed., Burntisland, 

George Dickson, M.D., CM., .... 
335 Elsie Maud Inglis, M.B., CM., 

George Robertson. L R.C.P. & S. Ed., Dunfermline, 

John Jeffrey, M.B., F.R.C.S. Ed., Jedburgh, . 

John Wishart Kerr, M.B., Ch.B., Glasgow, 

William Harold Graham Aspland, M.D., M.R.C.S. Eng. 
China, ...... 

340 William Taylor McArthur, M.D., F.R.C.S. Ed., California, 

Alexander Waddel Greenhorn Clark, M.B., CM., 

Henry Overton Hobson, M.D., CM., London,. 

Robert Patton Ranken Lyle, M.D., Ch.B., Newcastle-on- 
Tyne, ...... 

Frederick William Kerr Tough, L.R.CP. & S. Ed., St Helen' 
Junction, Lancashire, .... 
345 Robert Ashleigh Glegg, M.D., Ch.B., Leith, . 

Walter Scott Patton, M.B., Ch.B., India, 

David Whiteside Maclagan, M.B., Ch.B., New Zealand, 

Kennedy C M'llwraith, M.B., M.CP. & S. Ont., Toronto, 




35 i 










Robert Alexander John Harper, M.D., Ch.B., Dalkeith, 

William Hogg Prentice, M.D., Ch.B., Pendleton, 

Alexander Mowatt Malcolmson, M.D., Ch.B., Corstorphine, 

David Albert Callender, M. B. , Ch. B. , Knutsford, 

Caleb Williams Saleeby, M.D., Ch.B., London, 

John Andrew Douglas Thompson, Halesowen, 

John Ligertwood Green, M. D., Ch.B., 

William Sloss, M.B., Ch.B., Australia, 

Charles James Hill Aitken, M.D., CM., Cape Colony, 

E. R. Secord, M.D., Ontario, . 

F. E. Thompson, M.D., Montreal, 
John M 'Gibbon, M.B., CM., 
Thomas James Thomson, M.D., CM., 
Charles Mowbray Pearson, M.B., Ch.B., 
Ewen John Maclean, M.D., M.R.C.P. Lond., Cardiff, 
James William Somerville, M.D., CM., Galashiels, 
Alexander Miller, L.R.C.P. Ed., L.F.P.S. Glasg., Glasgow, 
Hugh Faulkner, M.B., Ch.B , Banbury, 
Duncan Macnab Callender, M.B., Ch.B., Lancaster, 
Robert Cranston Low, M.B., Ch.B., . 
Benjamin Philip Watson, M.B., Ch.B., 
John Macdonald, M.B., CM., Cupar-Fife, . 
Mabel Hardie, M. B. , Ch. B, , Stockport, 
John Sullivan, M.B., Ch.B., . 
Charles William Somerville, M.B., Ch.B., China, 
Frank Mayes Willcox, M.B., CM., . 
John Tennant, M.B., CM., Scunthorpe, 
Alexander Simpson Wells, M.B., F.R.CS. Ed., Cape 
Andrew Binny Flett, M.B., Ch.B., 
William Henry Eden Brand, F.R.CS. Ed., L.R.C, 

Banchory, .... 

Francis Cavanagh, M.B., Ch.B., Sheffield, 
Alfred Lambre White, L.R.C.P. & S. Ed., Manchester, 
Robert Bathgate Johnston, L.R.C.P. & S. Ed., Penrith 
William Llewellyn Jones, M.D., F.R.CS. Ed., Merthyr 

Tydvil, ...... 

Robert Wilson Gibson, M.D., F.R.CS. Ed., Orton, . 

Philip Henry Mules, M.B., Ch. B., New Zealand, 

Andrea Francis Honyman Rabagliati, M.D. , Ch.B., Bradford 

Donald Gregor MacArthur, M.D., CM., Aberfcldy, . 

Henry Martyn Stumbles, M. B., Ch.B., Amble, 

Gilbert John Farie, M.B., Ch.B., Bridge of Allan, 

Cameron Robertson Gibson, M.B., Ch.B., Gretna, 

James Mathieson Kirkness, M.D., Ch.B., 

Katherine Jane Stark Clark, M.D., Ch.B., D.P.H., . 

David Halliday Croom, M.D., Ch.B., . 

Eleanor Russell Elder, M.B., Ch.B., Leith, . 

Robert William Johnstone, M.D., Ch. B., 

James William Keay, M.D., Ch.B., 

Ivan Cochrane Keir, M.D., Ch.B., Melksham, . 

Alexander Grant Macdonald, M.B., CM., 

Charles John Shaw, M.D., Ch.B., Montrose, . 

Frederick Porter, M.B., CM., .... 

Sherwin Gibbons, M.D., Los Angeles, 

Russell Gerald William Adams, M.D. , Ch.B., New Zealand, 

Duncan Campbell Lloyd Fitzwilliams, M.D., Ch.B, 

London, . 
Clarence Brian Dobell, M.B., M.R.C.S. Eng., M.R.C.P.L, 

Cheltenham, ..... 



Date of 



















Hugh Stevenson Davidson, M.B. , Ch.B., 

Andrew Milroy Fleming, C.M.G., M.B., F.R.C.S. Ed 

Rhodesia, ..... 
Thomas William Edmondston Ross, M.B., Ch.B., Cardiff, 
John Benjamin Hellier, M.D., M.R.C.S. Eng., Leeds, . 
John Thomas Williams, M. D. , Treharris, 
William Brown, M.B., Ch.B., Braemar, 
John Hepburn Lyell, M.D., CM.. Perth, 
Henry Hugh Robarts, M.D., Ch.B., Haddington, 
Thomas Garnet Stirling Leary, M.B., Ch.B., Australia, 
Robert Balfour Barnetson, M.B. , Ch.B., Portobello, . 
James Lochhead, M.D., Ch.B., Earlston, 
Arthur Charles Strain, M.D., Ch.B., West Hartlepool, 
Lewis Beesly, L.R. C.P.Ed., F.R.C.S. Ed., 
James Crawford Gibb Macnab, M.B., F.R.C.S. Ed., Dysart, 
Andrew Alexander Hall, M.B., Ch.B., . 
Robert William Lessel Wallace, M.B., Ch.B., Bournemouth, 
Alfred Thom Gavin, M.B., CM., Dunaskin, . 
Alastair MacGregor, M.D., CM., Market Harborough, 
Edmond Frost, M.D., CM., Eastbourne, 
Edith Cochrane- Brown Pitts, M.B., Ch.B., New Zealand, 
James Brownlee, M.D., Ch.B., Middlesbrough, 
William Joseph Maloney, M.D., Ch.B., Cairo, 
Peter M'Ewan, M.B., Ch.B., Bradford, 
George Douglas Mathewson, M.B., Ch.B., 
Henry Grey Brown, M.B., Ch.B., 

Richard James Harley, M.D., L.R.C.P. &S.Ed., Murruyjirld 
Andrew Fleming, M.B., Ch.B., Corstorphine, 
Robert William Craig, M.D., Ch.B., Ford, 
Henry John Dunbar, M.D., Ch.B., . 

Richard Alfred Blake, M.D., Ch.B., Pretoria, South Africa, 
John Herbert Gibbs, F.R.C.S. Ed., 
Alice Marion Hutchison, M.D., Ch.B., 
Barbara Martin Cunningham, M.B., Ch.B., India, 
W. T. Chouhall, M.D., Sydney, 

Alexander Angus Martin, F.R.C.S. Ed., North Shields, 
James Andrew Gunn, M.D., Ch.B., 
James Lawson Russell, M.B., Ch.B., Todmorden. 
Archibald M'Kendrick, L.R.C.P. k S.Ed., Kirkcaldy, 
Alexander Scott, M.B., CM., Broxburn, 
Archibald Simpson, M.B., Ch.B., Darlington, 
Hirjee Nowon Anklesaria, L.R.C.P. & S.Ed., Bombay, 
Archibald Cotterell M 'Master, M.B., Ch.B. . 
Arthur James Lewis, M.B. , Ch.B., 
Herbert Park Thompson, M.D., Ch.B., 
Samuel Davidson, M.D., CM., Kelso, 
William Fowler Godfrey, M.B., CM., 
H. St John Randell, M. B., Ch. B., Cape Colony, 
Kaikhuson Dadabhoy, F.R.C.S. Ed., L.R. C.P.Ed., India, 
William Joseph Baird, M.B., Ch.B., Earls Barton, . 
Edward Burnet, M.B., Ch.B., . 
Arthur Samuel Walker, M.B., Ch.B., Ashley, 
Archibald Dunlop Stewart, M. B. , L. R. C S. Ed. , 
Henry Fleet Gordon, M.D., L.R.C.P. & S. Ed., Winnipeg, 
Edward Alexander Elder, M.B., Ch.B., 
Ethelbert William Dyer, M. B., Ch.B. , London, 
William Torrance Smith, M.B., Ch.B., Midcalder, . 
Arnold Davies, M.B., Ch.B., Menai Bridge, . 
Thomas Graham Brown, M.B., Ch.B., 

Date of 








John Bruce M'Moreland, M.B., Ch.B., 

William Omand Sclater, M.B., Ch.B., 

Archibald George Kirkwood Ledger, M.B., Ch.B., Darwen, 
465 Frederick James Greig, L.R.C.P. & S.I., Lt.-Col., R.A.M.C. 
Stirling, ...... 

Duncan Lorimer, M.B., Ch.B., 

Charles Robert Paterson Mitchell, Glasgow, . 

William David Osier, ..... 

John Halley Meikle, M.D., .... 
470 David Lloyd Roberts, M.D., F.R.C. P., Manchester, . 

James Sutherland Edwards, M.B., Ch.B., 

Alexander Murray Drennan, .... 

Mary Caroline Hamilton, L.R.C.P. & S. Ed., L.F.P.S. Glasg 

Elsie Mary Macmillan Barnetson, M.B., Ch.B., Joppa, 
475 John Andrew Macleod, M.B., Ch.B., Inverness 

Hugh Smith Reid, M.D., Ch.B., 
477 Allan Macdonald Dick, M.B., Ch.B., . 

Date of 






Adam, Dr George Roth well, 84 Collins St., Melbourne, Aus., 

Anderson, Dr John, Newholme, Pitlochry, 

Ballantyne. Dr Harold S., Ashton, Eskbank, Dalkeith, 

Ballantyne, Dr J. W., 24 Melville Street, 
5 Barbour, Dr A. H. Freeland, 4 Charlotte Square, 

Barclay, Dr William John, Invercargill, New Zealand, 

Brock, Dr G. Sandison, 2 Via Veneto, Rome, 

Burnet, Dr Edward, 4 Fingal Place, . 

Cavanagh, Dr Francis, 396 Ecclesall Road, Sheffield, . 
10 Chipman, Dr W. W., 285 Mountain St., Montreal, Canada, 

Chouhall, Dr William T., 233 Macquarie St., Sydney, 
Australia, ...... 

Craig, Dr John, 71 Brunts field Place, . 

Craig, Dr William, 71 Bruntsfield Place, 

Croom, Dr David Halliday, 17 Alva St., 
15 Croom, Prof. Sir John Halliday, 25 Charlotte Square, 

Cumming, Dr John, 70 Bruntsfield Place, 

Dobell, Dr C. B., 1 Royal Well Terrace, Charlton, Cheltenham 

Dumat, Dr Henry Aylmer, 7 Devonshire Place, Durban 
Natal, South Africa, .... 

Fleming, Dr Andrew M., C.M.G., Salisbury, Rhodesia, 
20 Fowler, Dr Simson, Waverley, Juniper Green, 

Frost, Dr Edmund, Chesterfield, Meads, Eastbourne, . 

Gibson, Dr R. Wilson, Town Head House, Orton, Tebay, 

Grant, Dr Lewis, Neston, Cheshire, 

Hart, Dr D. Berry, 5 Randolph Cliff, . 
25 Inch, Dr Robert, Gorebridge, .... 

Johnston, Dr D. W., P.O. Box 2022, Johannesburg, Trans 
vaal, ...... 

Livingston, Dr George R., 47 Castle Street, Dumfries, 











M'Arthur, DrW. Taylor, 959 S. Figueroa St., Los Angeles, 

California , . 
M'Brearty, Dr J. Wilson, Greymouth, West Coast, New 

Zealand, ....... 

M'Farlane, Dr Hilda M., Bendameer, Burntisland,- . 

Macnab, Dr James, C. G., The Towers, Dysart, 

Maddox, Dr Ralph H., I. M.S., c/o Messrs Thomas Cook & 

Son, Ludgate Corner, London, E.C., 
Martin, Dr Christopher, Cleveland House, George Road, 

Edgbaston, Birmingham, . . . . . 

Melville, Dr Kenmure, 2 Nile Grove, . . . 

Morgan, Dr T. H., Gympie, Queensland, Australia, . 
Mules, Dr P. Henry, Bishopdale, Nelson, New Zealand, 
Pereira, Dr A. A. Jervis, Consul de Grece en Mozambique, 

Lourenco. Marques, Delagoa Bay, South Africa, . 
Pitts, Dr Edith Cochrane-Brown, Strathmore, Christ Church, 

New Zealand, ..... 

Ponder, Dr Charles F., Glenorchy, Hobart, Tasmania, 
Ranking Dr J. E., Tunbridge Wells, . 
Ross, Dr James F. W., 481 Sherbourne Street, Toronto, Canada 
Russell, Dr J. Lawson, West Lodge, Tormorden, 
Simpson, Dr G. F. Barbour, 50 Melville Street, 
Simpson, Dr W. Petrie, Viewbank, Bathgate, 
Simson, Dr H. J. F., 36 Grosvenor Street, London, W., 
Struthers, Dr John, Nqamakwe, Transkei, South Africa, 
Vatve, Dr Gopal Govind, c/o H.H. The Rajah of Miruj 

Bombay, India, ..... 
Wells, Dr A. Simpson, 56 Orange Street, Cape Town, South 

Africa, ....... 

Date of 










Aarons, Dr S. Jervois, 14 Stratford Place, London, W., . 1896 

50 Adams, Dr Russell G. W., Langley Dale, Blenheim, New 

Zealand ....... 1904 

Affleck, Dr J. O., 38 Heriot Row, . . . . 1869 

Ainslie, Dr A. C, 49 Minto Street, .... 1898 

Aitken, Dr C. J. Hill, 19 Church Street, corner of Oxford 

Street, East London, South Africa. . . . 1902 

Alexander, Dr W. B., 8 Blenheim Place, . . . 1882 

55 Allison, Dr J., Fuller House, Kettering, Northampton, . 1888 

Anderson, Dr Fred. T., 20 In verleith Row, . . . 1892 

Andrew, Dr James, 2 Atholl Crescent, .... 1868 

Anklesaria, Dr H. N., 12 Colaba Causeway, Bombay, India, . 1906 

Archibald, Dr J., Hazelden, Wimborne Road, Bournemouth, 1877 

60 Armitage, Dr J. A., 58 Waterloo Road Wolverhampton, . 1886 

Armour, Dr E. F., 6 Bruntsfield Terrace, . . . 1889 

Aspland, Dr W. H. Graham, Church of England Mission, 

Peking, China, . . . . . . 1901 

Baildon, Dr F. J., 42 Hoghton Street, Southport, . . 1887 

Baird, Dr W. J., Earls Barton, Northants, . . . 1906 

65 Ballantyne, Dr A., Ashton, Eskbank, Dalkeith, . . 1870 

Barnardo, Dr F. A. F., Capt. I. M.S., Ferozepore, Punjab, 

India, . . . ..... . 1899 

Barnetson, Dr Elsie M„ 31 Morton Street, Joppa, ' . . 1907 














Barnetson, Dr R. Balfour, 31 Morton Street, Portobello, 
Barrington, Dr Fourness, 213 Macquarrie Street, Sydney, 

Australia, ...... 

Barry, Dr W. J. M., 29 Plymouth Road, Penarth, Glamorgan, 

Bateman, Dr F. J.Harvey, Heath End, Blackheath, Lond. ,S.E 

Beatty, Dr Samuel, Craigvar, Pitlochry, 

Beesley, Dr R. W., 135 Deane Road, Bolton, . 

Beesly, Dr Lewis, 13 Torphichen Street, 

Bell, Dr J. Lumsden, Driffield, Yorkshire, 

Bentley, Dr G. H., Loanhead House, Kirkliston, 

Beveridge, Dr Robert, 9 James Place, Leith, . 

Blaikie, Dr R. H., 10 Mayfield Gardens, 

Blair, Dr J. A., 16 Windsor Terrace, Newcastle-on-Tyne, 

Blake, Dr R. A., Padn oiler, Sunnyside, Pretoria, South Africa 

Bleloch, Dr A., 26 Gilmore Place, 

Boddie, Dr G. P., 73 Brimtsfield Place, 

Booth, Dr William, 2 Minto Street, . 

Borrowman, Dr Philip G., Galvelmore, Crieff, 

Boxill, Dr N. L., Buttalls, St George, Barbados, 

Brand, Dr Eden, Bellfield, Banchory, . 

Brewis, Dr N. T., 6 Drumsheugh Gardens, 

Brewis, Dr R. Adams, The West Gate, Dursley, Gloucestershire 

Broad, Dr B. W., The Sanitorium, Cardiff, 

Brodie, Dr T. Scott, 21 Belhaven Terrace, Wishaw, 

Brodie, Dr W. Haig, 6 St Stephen's Road West, West 

Ealing, London. W. 
Brown, Dr H. Grey, 1 Cluny Avenue, . 
Brown, Dr J. Graham, 3 Chester Street, 
Brown, Dr William, Braemar, .... 
Brownlee, Dr James, 6 Seaton Terrace, Linthrope Road 

Middlesbrough, ..... 
Buist, Dr J. W., 1 Clifton Terrace, . 
Buist, Dr R. C, 166 Nethergate, Dundee, 
Bunting, Dr W. Hartley, 20 Hagley Road, Edgbaston 

Birmingham, ..... 

Burton, Dr Thomas J., Port Hedland, West Australia, 
Butchart, Dr C. A., 52 Leith Walk, Leith, 
Cairns, Dr W. Murray, 67 Catherine Street, Liverpool, 
Calder, Dr H. L., 60 Leith Walk, Leith, 
Callender, Dr D. A., Hazelmere, Toft Road, Knutsford, 

Cheshire, ..... 
Callender, Dr D. M., 6 Rose Bank, Lancaster, 
Callender, Dr T. M., Inverard, Sidcup, 
Cameron, Prof. James C, M.D., 941 Dorchester Street 

Montreal, ..... 
Campbell, Dr Malcolm, 17 Walker Street, 
Carmichael, Dr Edward, 21 Abercromby Place, 
Carmichael, Dr E. W. Scott, 32 Rutland Square, 
Carmichael, Pr James, 22 Northumberland Street, 
Carrnthers, Dr G. J. R., 4 Melville Street, 
Cattanach, Dr J. G., 3 Alvanley Terrace, 
Church, Dr H. M., 36 George Square, . 
Clark, Dr A. W. G., 24 Braid Crescent, 
Clark, Dr J. A., 4 Cambridge Street, 
Clark, Dr Katherine S., Craigleith Poorhouse, 
Cobbett, Dr C. N., Edmonton, Alberta, Canada, 
Cox, Dr Joshua J., 38 Deansgate, Manchester, 
Craig, Dr R. W., Pathhead-Ford, Dalkeith, . 
Oroudace, Dr J. H., Foregate House, Stafford, 

Date of 






















Cullen, DrG. M., 50 Minto Street, . 

Cunningham, Dr Barbara M., Dufferin Hospital, Nagpur 

Central Provinces, India, . 
Currie, Dr A. S., 20 Oxford Terrace, Hyde Park, London, W. 
Dadabhoy, Dr K., Karachi, India, 
Darling, Dr T. Brown, 1 3 Merchiston Place, . 
Darling, Dr William, 2 Warrender Park Terrace, 
Davidson, Dr D. G., 9 Granville Terrace, 
Davidson, Dr H. S., 4 Dundas Street, . 
Davidson, Dr Samuel, Kelso, .... 
Davies, Dr Arnold, Grammar School, Menai Bridge, North 

Wales, ...... 

Davies, Dr E. T. , 1 St Domingo Grove, Liverpool, 

Dendle, Dr Frank, Overton House, Spring Grove, Isleworth, 

Deverell, Dr H. C, 12 Windsor Street, 

Dewar, Dr M., 24 Lauriston Place, 

Dick, Dr A. Iff., Edinburgh University Union, 

Dickie, Dr J. T., 37 Lauriston Place, . 

Dickson, Dr George, 9 India Street, 

Dickson, Dr George, 14 Ardmillan Terrace, 

Dobie, Dr D. Robertson, Heathfield, Crieff, 

Donald, Dr C. W., 28 Portland Square, Carlisle, 

Drennan, Dr A. Murray, 36 Woodburn Terrace, 

Dunbar, Dr H. J., 1 Kew Terrace, 

Duncan, Dr A. J., 158 Nethergate, Dundee, . 

Duncan, Dr A. S., ..... 

Dunlop, Dr H. M., 20 Abercromby Place, 

Dyer, Dr E, W., c/o Messrs Webster, Steel & Co., 5 East 

India Avenue, Leadenhall Street, London, E.C., . 
Eason, Dr John, 58 Northumberland Street, . 
Easterbrook, Dr A. M., Am prior, Gorebridge, 
Easterbrook, Dr C. C, Glengall, Ayr, . 
Easton, Dr Thomas, 23 East Park Terrace, Southampton, 
Eden, Dr T. Watts, 26 Queen Anne Street, Cavendish Squar 

London, W. , . . 

Edington, Dr D. C, 4 Portland Place, Penrith, 
Edwards, Dr J. S., University Union, 
Elder, Dr Edward A., 6 Torphichen Street, 
Elder, Dr Eleanor, 4 John's Place, Leith, 
Elder, Dr W. Nicol, 6 Torphichen Street, 
Evans, Dr O. F., 20 Princes Avenue, Liverpool, 
Farie, Dr G. J., Strathallan House, Bridge of Allan 
Farquharson, Dr J. D., 242 Westgate Road, Newcastle-on 

Tyne, ...... 

Faulkner, Dr Hugh, St John's House, Banbury, Oxon 
Felkin, Dr R. W., 12 Oxford Gardens, North Kensington 

London, W., .... 

Ferguson, Dr J. Haig, 7 Coates Crescent, 
Ferguson, Dr P. J. H. , 9 Windsor Street, 
Ferguson, Dr R. T., Middlemarch, Anstruther, Fife, . 
Finlay, Dr W. A., 50 Trinity Road, . 
Fitzwilliams, Dr D. C. L., 64 Brook Street, Grosvenor Square 

London, W., ..... 

Fleming, Dr Andrew, St John's Road, Corstorphine, . 
Flett, Dr A. B., 60 George Square, 
Forbes, Dr J. Christie, Ardv* ich, Liberton, 
Fordyce, Dr A. Dingwall, 19 Coates Crescent, 
Fordyce, Dr William, 20 Charlotte Square, 
Fothergill, Dr W. Edward., 13 St John Street, Manchester, 

Date of 












Forrester, Dr C. C, 3 Albert Terrace, . 

Fowler, Dr W. Hope, 5 St Vincent Street, 
175 Fox, Dr J. W., 18 Bernard Street, Southampton, 

Fraser, Dr J. Hossack, Fernfield, Bridge of Allan, 

Fraser, Dr Nutting S., 205 Gower Street, St John's, New 
foundland, ...... 

Frost, Dr W. E., 6 Atholl Place, 

Garbutt, Dr W. J., 1 Bournbrook Rd., Selly Pk., Birmingham 
180 Gardiner, Dr Frederick, 9 George Square, 

Gavin, Dr Alfred T., Doonlea, Dunaskin, 

Gayton, Dr William, Ravensworth, Regent's Park Road 
Finchley, London, N., 

Gemmell, Dr J. E., 28 Rodney Street, Liverpool, 

Gibbons, Dr Sherwin, 1013 Braly Building, Los Angeles, 
California, ...... 

185 Gibbs, Dr J. H., 7 Coates Place, 

Gibson, Dr Cameron R., 101 Forest Road, Nottingham, 

Giffen, Dr J. T. M., 138 Boughton, Chester, . 

Giles, Dr A. B., 4 Palmerston Place, . 

Gilmour, Dr T. F., Port Ellen, Islay, . 
190 Glegg, Dr R. Ashleigh, Public Health Office, Leith, . 

Godfrey, Dr W. F., 46 Cumberland Street 

Gordon, Dr Henry F., 178 Colony Street, Winnipeg, Canada. 

Graham, Dr A., Curriebank, Currie, 

Graham, Dr D. J., 26 Rutland Street, . 
195 Graham, Dr F. M., 16 Mayfield Gardens, 

Graham, Dr J. Gibson, 17 Ashton Ter., Dowanhill, Glasgow 

Graham, Dr R. Balfour, Leven, Fife, . 

Green, Dr John Ligertwood, 23 Minto Street, . 

Greene, Dr T. W. N., 45 Dartmouth Square, Leeson Park 
Dublin, ....... 

200 Gregory, Dr W. H., North Bar Street, Beverley, Yorks, 

Greig, Dr F. J., Lt.-Col. R.A.M.C., 16 Melville Ter., Stirling, 

Gunn, Dr . J. A., Materia Medica Department, University of 
Edinburgh, .... 

Guthrie, Dr A. Cowan, 21 Pilrig Street, 

Hall, Dr A. A., 8 Vanburgh Place, Leith, 
205 Hall, Dr D. G., 30 Brunswick Place, Hove, Brighton 

Hamilton, Dr J. R., Elm House, Hawick, 

Hamilton, Dr Mary, Pengarth, St Agnes, Cornwall, 

Hamp, Dr J. Walton, Penn Road, Wolverhampton, 

Hardie, Dr Mabel, High Lane, near Stockport, 
210 Harley, Dr R. J., .... 

Harlin, Dr Francis W., Peak Downs District Hospital 
Clermont, Queensland, .... 

Harper, Dr R. A. J., Abbey Road, Barrow-in-Furness 

Harvey, Dr Charles E., Kingswood, Sav-la-Mar, Jamaica 
W.I., .... 

Harvey, Dr James, 7 Blenheim Place, . 
215 Haultain, Dr F. W. N., 12 Charlotte Square, 

Havelock, Dr J. G., Sunnyside, Montrose, 

Hay, Dr Henry, 11 Great King Street, 

Hellier, Dr J. B., Glengariff, North Grange Road, Headingley 
Leeds, ..... 

Helm, Dr J. H. , Clarence Cottage, Ratho, 
220 Helm, Dr R. Dundas, 13 Portland Square, Carlisle, 

Helme, Dr G. Edgar, Gloucester House, Rusholme, Manchester 

Henderson, Dr Alexander, 21 Pitt Street 

Hewetson, Dr J., Holmfield 

Date of 











Hindmarsh, Dr Edwin, Mozufferpore, Tirhoot State Railway 
Bengal, India, ..... 
225 Hobson, Dr H. Overton, Villa Sakkara, Helouan, Egypt 

Hoggan, Dr Robert, Liberton Park, Liberton, . 

Holmested, Dr C. W., Tuxford, Newark, Notts, 

Hughes, Dr H. L., Llwyn-Werm, Dowlais, Glamorganshire, 

Hughes, Dr P. T., County Asylum, Broomsgrove, Worcester 
shire, .... . 

230 Hunter, Dr George, 33 Palmerston Place, 

Hutcheson, Dr J. , 44 Moray Place, 

Hutchison, Dr Alice M., 204 Bruntsfield Place, 

Inglis, Dr Elsie M., 8 Walker Street, . 

Jamieson, Dr Hugh, 1 Strathearn Road, 
235 Jamieson, Dr J. Boyd, 43 George Square, 

Jardine, Dr Robert, 20 Royal Crescent, Glasgow, W., 

Jeffrey, Dr John, Glen Bank, Jedburgh, 

Johnston, Dr Robert B., Bishopyards, Penrith, 

Johnston, Dr R. J., 1 Buccleuch Place, 
240 Johnstone, Dr R. W., 13 Torphichen Street, . 

Jones, Dr W. Llewellyn, 58 Thomas St., Merthyr-Tydvil, 

Keay, Dr J. W., 12 Brougham Place, . 

Keiller, Prof. Wm., 210 Levy Building, Galveston, Texas 

Keir, Dr Ian C, The Limes, Melksham, Wilts, 
245 Ker, Dr Claude B., City Hospital, Comiston Road, 

Kerr, Dr J. M. Munro, 7 Clairmont Gardens, Glasgow, 

Kerr, Dr J. Wishart, 107 Greenhead Street, Glasgow, 

King, Dr J. K., The Glen Springs Sanitorium, Watkins 
New York, U.S.A., ..... 

Kirk, Dr Robert, Rowan Bank, Bathgate, 
250 Kirkness, Dr J. M., 14 Dalkeith Road, 

Kynoch, Professor Campbell, 8 Airlie Place, Dundee, . 

Lackie, Dr James, 1 Randolph Crescent, 

Laing, Dr J. H. A., 11 Melville Street, 

Langwell, Dr H. G., 4 Hermitage Place, Leith, 
255 Leary, DrT. Garnet S., Grand Hotel, Melbourne, Australia, 

Ledger, Dr A. G. K., 97 Blackburn Road, Darwen, . 

Lee, Dr Herbert E., Gunnedah, N.S.W., Australia, 

Lewis, Dr Arthur J., c/o R Shaw, Esq., 36 Woodburn Terrace 

Littlejohn, Professor Harvey, 11 Rutland Street, 
260 Lochhead, Dr James, Earlston, 

Lockhart, Dr F. A. L., 23 Mackay Street, Montreal, Canada, 

Lorimer, Dr Duncan, 74 Bruntsfield Place, 

Low, Dr R. Cranston, 6 Castle Terrace, . . 

Lvell, Dr John, 15 Marshall Place, Perth, 
265 Lyle, Dr F. W., 97 Gordon Road, Ealing, London, W., ' 

Lyle, Dr R. P. Ranken, 11 Ellison Place, Newcastle-on-Tyne 

Mac Arthur, Dr D. G., Aberfeldy, 

M'Call, Dr John, 25b Abercromby Terrace, Portobello, 

M'Callum, Dr H., Kinloch-Rannoch, . 
270 M'Cann, Dr F. J., 5 Curzon Street, Mayfair, London, W.. 

Macdonald, Dr Alexander, 42 Polwarth Terrace, 

Macdonald, Dr A. G., 11 Manor Place, 

Macdonald, Dr Angus, 27 Manor Place, 

Macdonald, Dr John, Marathon House, Cupar-Fife, . 
275 Macdonald, Dr W. Fraser, 16 Buckingham Ter., Glasgow, AY 

M'Ewan, Dr Peter, Royal Infirmary, Bradford, Yorks, 

M'Gibbon, Dr John, 22 Heriot Row, . 

MacGregor, Dr Alastair, Stafford Lodge, Market Harborough 

Date of 


















MacGregor, Dr A. V., Durham House, West Hartlepool, 

MacGregor, Dr Donald, Seaton House, Jedburgh, 

Macgregor, Dr G. S., 2 Burnbank Terrace, Glasgow W., 

M'llwraith, Dr Kennedy C, 54 Avenue Rd., Toronto, Canada 

Mackay, Dr George, 74 Bruntsfield Place, 

Mackay, Dr W. B., 23 Castlegate, Berwick-on-Tweed, 

M'Kendrick, Dr Archd., 120 High St., Kirkcaldy, 

Mackenzie, Dr R., Napier, Nairn, 

Mackenzie, Dr T. C, Aberdeen Royal Asylum, 

M'Kerron, Dr R. Gordon, 1 Albyn Place, Aberdeen, . 

Mackie, Dr George, Boyd's Lodge, Malvern, Worcestershire, 

Mackin, Dr Patrick, 12 Ingestre St., Wellington, New Zealand, 

Mackness, Dr G. O. C., Fort Street House, Broughty-Ferry 

Maclagan, Dr D. W., Kaponga, Taranaki, New Zealand, 

M'Larty, Dr Malcolm, 7 Bellevue Place, 

M'Lean, Dr Archibald, Crosshouse, Kilmarnock, 

Maclean, Dr Ewen, J., 12 Park Place, Cardiff, 

Macleod, Dr J. A., The Asylum, Inverness, 

M 'Master, Dr A. C, Australasian Club, Melbourne Place, 

Macmillan, Dr John, 48 George Square, 

M'Morland, Dr J. B., 19 Merchiston Gardens, 

MacRae, Dr John, Lynwood, Murray field, 

Mac Vie, Dr S. , Chirnside, .... 

M'Watt, Dr John, Duns, .... 

Macwatt, Dr R. C, 7th Bengal Cavalry, c/o Messrs King, 

King & Co., Bombay, India, 
Malcolmson, Dr Alexander M., Dalveen, St John's Road 

Corstorphine, ..... 

Maloney, Dr W. J., Kasr-El. Aing. Hospital, Cairo, . 
Manford, Dr J. Stanley, 1 Osborne Terrace, Newcastle-on 

Tyne, ....... 

Marshall, Dr G. Balfour, 19 Sandyford Place, Glasgow, 
Marshall, Dr William, Milnathort, 

Martin, Dr Angus, 25 Northumberland Square, North Shields 
Martin, Dr Charles, Dagenham House, Newton Abbot, South 

Devon, ...... 

Martin, Dr J. W., Charterhall, Newbridge, Dumfries, 

Matheson, Dr A. A., 41 George Square, 

Matheson, Dr Roderick M., 33 Buccleuch Place, 

Mathewson, Dr G. P., 25 Cluny Gardens, 

Maurange, Dr Gabriel, 6 Rue de Tournon, Paris, 

Meikle, Dr J. Hally, 12 Midmar Gardens, 

Menzies, Dr David, 20 Rutland Square, 

Messer, Dr Fordyce, Woodlands, Garelochhead, 

Michael, DrGustave, 5 Cambridge Place, Chestergate, Regent 

Park, London, N.W., 
Millard, Dr W. W., Middlefield House, Leith Walk, . 
Miller, Dr Alexander, 1 Royal Terrace, Crossbill, Glasgow, 
Miller, Dr W. H., 51 Northumberland Street, . 
Milne, Dr W. M., 10 Newington Road, 
Mitchell, Dr C. R. P., 1 Bowmont Gardens, Glasgow, 
Mitchell, Dr G. B., 1 Skinner Street, Whitby, 
Mitchell, Dr R. M., Government Hospital, Coolgardie 

Western Australia, ..... 

Montgomery, Dr John, The Highlands, Balsall Heath 

Birmingham, ..... 

Moorhouse, Dr J. Ernest, 6 Melville Terrace Stirling, 
More, Dr James, Rothwell, Kettering, Northampton, . 
Morison, Dr Albert E., Wellington Road, West Hartlepool, 

Date of 












Morris, Dr S. Glanville, Brynawel, Mardy, Glamorganshire 

Moses, Dr 0. St John, 8 Lansdovvne Road, Calcutta, . 

Mowat, Dr John, 5 Hope Park Terrace, 

Munro, Dr J. Ramsay, Sutter ton, Boston, 
335 Murray, Dr A. Lang, Killara, Sydney, N.S.W., Australia, 

Murray, Dr D. R., 41 Albany Street, Leith, 

Murray, Dr James, 1 Brandon Street, . 

Napier, Dr A. D. Leith, 28 Angas Street, Adelaide, South 
Australia, ...... 

Nicholson, Dr H. Oliphant, 20 Manor Place, . 
340 Ogdcn, Dr Watson, 38 Jesmond Road, Newcastle-on-Tyne 

Ogilvy, Dr Stewart Grant, Fairmont, Fauldhouse, 

Oliphant, Dr E. H. Lawrence, 23 Newton Place, Glasgow, 

Orr, Dr John, Heather Lea, Clarendon Road, Eccles, Lanes., 

Orr, Dr W. Basil, 13 Braid Road, 
345 Osier, Dr W. D., 11 Montgomery Street, 

Paterson, Dr G. Keppie, 19 Albany Street, 

Paterson, Dr G. W. Simla, 147 Kruntsfield Place, 

Patton, Dr W. Scott, Capt., I. M.S., " Scotts Burn," Landour 
Mussoorie, N.W.P., India, 

Pearson, Dr C. M., 14 Manor Place, . 
350 Peddie, Dr H. Anderson, 24 Palmerston Place, 

Perigal, Dr A., New Barnet, Herts, 

Pirie, Dr John, 15 Ardmillan Terrace, 

Playfair, Dr John, 5 Melville Crescent, 

Poole, Dr T. D., North Side House, Linthwaite, near 
Huddersfield, ..... 

355 Porritt, Dr E. E., Wanganui, New Zealand, . 

Porteous, Dr J. Lindsay, 83 Warburton Avenue, Yonkei 
New York, ...... 

Porter, Dr Frederick, 65 Morningside Road, 

Potts, Dr W. A., 118 Hagley Road, Edgbaston, Birmingham, 

Prentice, Dr W. H., Brunswick - Terrace, Brood Street, 
Pendleton, Manchester, . 
360 Price, Dr A. W. Gordon, 9 Grange Road, 

Price, Dr E. F. T.. 1 Middleby Street, 

Primrose, Dr Alex., 100 College Street, Toronto, Canada, 

Pringle, Dr J. Hogarth, 172 Bath Street, Glasgow, . 

Proudfoot, Dr Thomas, 30 Lauriston Place, 
365 Rabagliati, Dr A. H., 1 St Paul's Road, Bradford, Yorkshire, 

Randell, Dr H. St John, Aliwal North, Cape Colony, 

Reid, Dr H. S., 5 Ravelston Park, . . 

Reid, Dr W. L., 7 Royal Crescent W., Glasgow, 

Rendell, Dr Herbert R., P.O. Box 606, St John's, New- 
foundland, . . . . . . • . 

370 Rhodes, Dr J. H., Vicarage Terrace, Kendal, . 

Ritchie, Dr James, 22 Charlotte Square, 

Ritchie, Dr W. T., 9 Atholl Place, . . . . 

Robarts, Dr Henry H., Wemyss Place, Haddington, . 

Roberton, Dr Ernest, Cotele House, Symond Street, Auck- 
land, New Zealand, . 
375 Roberts, Dr D. Lloyd, 11 St John Street, Manchester, 

Roberts, Dr Ernest T., Oaklands House, Keighley, 

Roberts, Dr R. W. , Grove Place, Port Talbot, Glamorganshire, 

Robertson, Dr George, Braehrad, Viewfield Place, Dunfermline, 

Robertson, Dr Robert, 26 Royal Circus, 
380 Robertson, Dr W. B., St Anne's, 101 Thurlow Park Road, 
West Dulwich, London, S.E., . . . . 

Robertson, Dr W. G. Aitchison, 26 Minto Street, 

Date of 























Robins, Dr H., Sav-la-Mar, Jamaica, W.I., 

Robinson, Dr H. Shapter, Talfourd House, 78 Peckham Road 

Camberwell, London, S.E., 
Ronaldson, Dr T. R., 8 Charlotte Square, 
Rosa, Dr Albert F., 28 Pitt Street, 
Ross, Dr J. W. E., 1 Clare Street, Cardiff, 
Russell, Dr W., 3 Walker Street, 
Saleeby, Dr C. W., 13 Greville Place, London, N.W. 
Sandstein, Dr Alfred C, 23 Latimer Square, Christchureh 

New Zealand, . 
Saunders, Dr F. A., Grahamstown, Cape Colony, South 

Africa, ...... 

Schofield, Dr Linn J., Warrensburg, Mo., U.S.A., 
Sclater, Dr W. O., 16 War render Park Crescent, 
Scott, Dr Alexander, The Firs, Broxburn, 
Scott, Dr T. R., Musselburgh, .... 

Secord, Dr E. R., 112 Market St., Brantford, Ontario, Canada 

Shaw, Dr C. J., Royal Lunatic Asylum, Montrose, 

Shaw, Dr W. J., Cockburnspath, 

Shearer, Dr Alfred, Newtown, N. Wales, 

Simpson, Dr Archibald, The Hospital, Darlington, 

Simpson, Dr F. D., 7 Kew Terrace, 

Slight, Dr J. D., 61 London Road, Leicester, 

Sloan, Dr Allen T., 22 Ahercromby Place, 

Sloan, Dr S., 5 Somerset PI., Sauchiehall St. West, Glasgow, 

Sloss, Dr William, Windsor, Sturt Street, Ballarat, Mel 

bourne, Australia, .... 

Smart, Dr David, 74 Hartington Rd., Sefton Park, Liverpool, 
Smith, Dr G. H. Walton, Pendower, Oxford St., Paddington, 

Sydney* Australia, ...... 

Smith, Dr Gains T., 15 Church Street, Moncton, New Brunswick, 

.Canada, ...... 

Smith, Dr James, 4 Brunton Place, 

Smith, Dr John, Hrycehall, Kirkcaldy, 

Smith, Dr W. Ramsay, Winchester St., East Adelaide, Aus 

Smith, Dr W. Torrance, Linwood, Midcalder, 

Sneddon, Dr William, 58 Bonnygate, Cupar-Fife, 

Somerville, Dr C. W., London Mission, Wuchang, by Hankow 

Central China, ..... 
Somerville, Dr James W., 12 Abbotsford Road, Galashiels, 
Spalding, Dr William, Gorebridge, 
Spence, Dr R., St Ninians, Burntisland, 
Spence, Dr William. Sydney House, Dollar, 
Stephen, Dr W. A., Loftus-in-Cleveland, Yorkshire, . 
Stevens, Dr John, 78 Polwarth Terrace, 
Stewart, Dr A. D., 8 Brougham Place, 
Stewart, Dr J. S.. 15 Merchiston Place, 
Stewart, Dr R., 25 George Square, 
Stirling, Dr R,, 4 Atholl Place, Perth, 
Story, Dr B. S. , Wellington, New Zealand, . 
Strain, Dr Arthur C. , Grange House, West Hartlepool, 
Stumbles, Dr H. M., Amble House, Amble, Northumberland 
Sturrock, Dr J. F., Arima, Bronghty-Ferry, . 
Sullivan, Dr John, 34 Gilmore Place, . 
Taylor, Dr David R., St Helen's, Ayton, 
Taylor, Dr William, 12 Melville Street, 
Taylor, Dr W. Macrae, 12 Melville Street, 
Teacher, Dr C, Ciaieend, North Berwick, 
Temple, Dr G. H., Ailanthus, Weston-super-Mare, 

Date of 























Tennant, Dr John, Scunthorpe, near Doncaster, 
Thatcher, Dr C. H., 8 Melville Crescent, 
Thin, Dr Robert, 25 Abercromby Place, 
Thomas, Dr G. Crewdson, 34 West Hill, Sydenham, London 
S.E., ...... 

Thompson, Dr F. E., 20 Park Avenue, Montreal, Canada, 
Thompson, Dr Herbert P., c/o Mackay, 52 Morningside Road 
Thompson, Dr James L., Castlemaine, Victoria, Australia, 
Thompson, Dr John A. Douglas, Comberton House, Hale- 
sowen, Worcestershire, .... 

Thomson, Dr A. D. R., 19 Bridge Street, Musselburgh, 
Thomson, Dr John, 14 Coates Crescent, 
Thomson, Dr J. Stitt, Castle Hill House, Lincoln, 
Thomson, Lr T. J., 31 Morningside Road, 
Thyne, Dr T. J., 16 Randolph Crescent, 
Tod, Dr John, 69 Ferry Road, Leith, . 

Tough, Dr F. W. K., 24 Junction Lane, St Helen's Junction 
Lancashire, ..... 

Tristan, Dr R. J. , 28 Carolgate Retford, Notts, 
Underhill, Dr C. E., 8 Coates Crescent, 

Underhill, Dr T. Edgar, Dunedin, Barnt Green, Worcestershire 

Vassie, Dr Alexander H., 98 Priory Road, West Hampstead. 

London, N.W., . 

Vickery, Dr W. H., 1 Trewartha Park, Weston-super-Mare, 

Wade, Dr George, St John's, Melrose, . 

Walker, Dr Arthur S., Ashleigh, Middlesborough, 

Wallace, Dr Abraham, 39 Harley Street, London, W. , 
Wallace, Dr R. W. L. , The Royal Boscombe and West Hants 
Hospital, Bournemouth, .... 

Watson, Dr B. P., 6 Castle Terrace, . 

Watson, Dr R. H. , Rousden, Park Road, Hamilton, . 

Waugh, Dr John, 36 Finsbury Pavement, London, E. C. , 

Webster, Dr A. D., 18 Minto Street, . 

Webster, Prof. J. C, 706 Reliance Building, 100 State Street 
Chicago, U.S.A., 

White, Dr A. L., Tantallon, Manchester Road, Castleton 
Manchester, ..... 

Wilcockson, Dr G. Morton, Whitley Cross, Reading, . 

Wilkie, Dr James, Selville House, Portobello, . 

Wilkinson, Dr George, 3 Dingle Hill, Liverpool, S., . 

Will, Dr J. C. Ogilvie, 17 Bon-Accord Square, Aberdeen, 

Williams, Dr J. T., Bronygar, Treharris, Glamorgan 
shire, ...... 

Willcox, Dr F. Mayes, 8 Strathearn Road, 

Wilson, Dr James, 53 Inverleith Row, . 

Wise, Dr Robert, 290 Ivy dale Road, Nunhead, London, S.E. 

Wood, Dr Thomas, 182 Ferry Road, . 

Woodside, Dr J. T. , Stewartstown, Co. Tyrone, 

Wright, DrW.F., . , . 

Yoe, Dr Richard T., 2103 Floyd Street, Louisville, Kentucky 
U.S. A 

Young, Dr H. C. Taylor, 209 Macquarrie Street, Sydney, New 
South Wales, ..... 

Young, Dr Peter A., 25 Manor Place, . 

Date of 



















Inaugural Address on the Future of Obstetrics. By J. W. 

Ballantyne, M.D., F.R.C.P.E., F.K.S.E. ... 3 

The Management of Some Difficult Occipito-Posterior Cases. By 

J. Lamond Lackie, M.D., F.R.C.P.(Ed.) ... 28 

On the Prognosis of Pregnancy in Patients with one Kidney, with 
Notes of an Unusually Complicated Case of Labour after 
Nephrectomy. By James Haig Ferguson, M.D., F.R.C.P.E., 
F.R.C.S.E., F.R.S.E . 57 

Successful Treatment of Puerperal Fever by Antistreptococcic 

Serum. By Dr Garnet Leary ..... 67 

Exophthalmic Goitre in its Relation to Obstetrics and Gynaecology. 
By Professor Sir Halliday Croom, M.D., F.R.C.P.E., 
F.R.C.S.E 143 

Epilepsy and the Status Epilepticus in connection with Pregnancy 
and Labour, with Illustrative Cases. By Professor Robert 
Jardine, M.D. (Ed.), F.F.P.S. (Glas.) . . . .165 

A Series of Five Cases of Cesarean Section for Contracted Pelvis. 
By Professor John A. C. Kynoch, M.B., F.R.C.P., 
F.R.C.S. (Ed.) 221 


Two Cases of Pregnancy complicated by Fibroid Tumours, treated 
by Hysterectomy. By N. T. Brewis, M.B., F.R.C.P.E., 
F.R.C.S.E 49 



Case of Acute Albuminuria, caused by the Pressure of a Tumour on 
both Ureters — Operation — Recovery. By Frederick Porter, 
M.B., CM. 75 

Intractable Uterine Haemorrhage, and Arterio- Sclerosis of the 
Uterine Vessels. By Elizabeth H. B. Macdonald, M.A., 
M.D., Ch.B 83 

A Clinical and Anatomical Study of Thirty Cervical Fibroids 
removed by Abdominal Hysterectomy. By F. W. N. 
Haultain, M.D., F.R.C.P. (Ed.) 121 

Hysterectomy for Fibroid Tumours in Pregnancy. Two Cases. 

By A. H. F. Barbour, M.D., F.R.C.P.E. . . .136 

Bilateral Ovarian Dermoid Tumours, complicating Pregnancy. By 

Malcolm Campbell, M.A., M.B., B.Ch., F.R.C.S.E. . .184 

Six Cases of Vaginal Cesarean Section. By N. T. Brewis, M.B., 

F.R.C.P.E., F.R.C.S.E 191 


A Case of Repeated Abortion due to Syphilis ; Treatment by 
Potassium Iodide. Birth of Child with Congenital Goitre. 
By B. P. Watson, M.D., F.R.C.S.E 204 

The " Byrth of Mankynde." (Its Contents.) By J. W. Ballantyne, 

M.D., F.R.C.P.(Edin.), F.R.S. (Edin.) . . . .236 




Foetus (extra-uterine), four months', removed by vaginal section ; 

and a portion of the placenta (Dr Brewis) . . . 140 

Foetus, frozen sections of, showing hidden cervical spina bifida (Dr 

J. W. Ballantyne) . . . . . . .121 

Kidneys, pair of cystic (adenomatous), from a still-born foetus 

(Dr J. W. Ballantyne) . . . . . .120 

Ovum, specimen of an early (Dr James Ritchie) . . . 48 

Pelvis (justo-minor, with rickets), from primipara who died in 

eclamptic coma (Dr Haig Ferguson) . . . .142 

Specimen, analogous to "Foetus Ovideus," obtained from a 

multipara (Dr Haultain) ...... 48 


(1) Fibkoid Tumours— 
(a) Simple — 

Fibroid, soft subperitoneal, resembling ovarian cyst, 
removed by abdominal hysterectomy (Dr Haig 
Ferguson) ...... 47 

Fibroid, multiple, giving rise to retention of urine (Dr 

Haultain) ...... 75 

Fibroid, cervical, growing from anterior wall of cervix and 

removed by pan-hysterectomy (Dr Brewis) . . 141 

Pelvic Abdominal Tumour, consisting of — (1) large sub- 
mucous fibroid j (2) fibroid between the layers of right 
broad ligament and united with the submucous 
fibroid (Dr Haig Ferguson) . , . .142 



(1) Fibroid Tumours — continued, 
(a) Simple — continued. 

Fibroid, cervical (Dr Fordyce) . . . . 1 04 

VA. Jfr. 

Fibroids, multiple, removed for pressure symptoms (Dr 

Fordyce) . . . . . . |f>4 

Fibroids, multiple, removed for post-climacteric haemor- 
rhage (Dr Fordyce) . . . . 1 64 

Uterus containing a large Submucous Fibroid attached by 

broad pedicle to fundus (Dr Brewis) . . . 190 

Fibroid, large soft oedematous, removed by hysterectomy 

(Dr Brewis) . . . . . .190 

Fibroid, cervical, weighing 12 lbs., causing retention of 
urine; removed by supravaginal hysterectomy 
(Professor Kynoch) ..... 220 

Mucous Polypus and Adenomatous Growth associated 

with Fibroid Uterus (3 specimens), (Dr Haultain) . 75 

Fibroids complicating Pregnancy — 

Uterus with large Cervical Fibroid, removed at the fifth 
month of pregnancy j Caesarean section and hyster- 
ectomy (Dr Brewis) . . . . . 44 

Uterus with Fibroid Tumour in lower uterine segment, 
removed at term by supravaginal hysterectomy after 
Caesarean section (colloid degeneration of the 
fibroid), (Dr Brewis) ..... 45 

Uterine Fibroid, complicated with pregnancy at fourth 

month, removed by hysterectomy (Professor Kynoch) 220 

(b) Degenerated — 

Fibroid, large subperitoneal, showing mucoid degeneration, 

with a very small pedicle (Dr Brewis) . . . 141 

Fibroid, interstitial, showing necrobiosis (Dr Fordyce) . 164 

(c) With malignancy — 

Uterus showing combined Fibroid Tumour and Carcinoma 

(Dr Fordyce) 164 


(2) Malignant Disease of Uterus — 


Uterus with Fundal Carcinoma, removed by vaginal hyster- 
ectomy from multipara eet. 55 (Dr Haig Ferguson) . 46 

Chorion Epithelioma of Uterus, removed by vaginal hyster- 
ectomy from patient set. 38 (Dr Haig Ferguson) . . 46 

Sarcomatous Uterus, round-celled, which filled entire cavity, 
perforated the wall, and involved the peritoneal cavity j 
abdominal section (Dr Haultain) .... 74 

Uterus with Adeno-carcinoma of body, removed per vaginam 

from multipara aet. 42 (Dr Haig Ferguson) . . 163 

Carcinoma of Uterus (3 specimens — 2 cervical, 1 corporeal), 

removed by vaginal hysterectomy (Dr Fordyce) . . 1 64 

Uterus with Adeno-carcinoma of the body, removed by vaginal 

hysterectomy from multipara set. 44 (Dr Haig Ferguson) 191 

(3) Other Uterine Conditions— 

Inverted Uterus of puerperal origin, removed by vaginal 

hysterectomy (Dr Haig Ferguson) .... 46 

Uterus (transformed into abscess cavity), removed by vaginal 
hysterectomy one year after double pyosalpinx had been 
removed by abdominal section (Dr Haig Ferguson) . 47 

Specimen of Diffuse Uterine Fibrosis (Dr Haultain) . . 74 

Uterus removed by abdominal hysterectomy for perforating 
abscess of its wall, arising from septicaemia after abortion 
(Dr Haultain) ...... 74 

Specimen showing Tubercular Endometritis (Dr Haultain) . 164 

Uterus removed by vaginal hysterectomy for bleeding (and, 
from same patient, a Haematoma of left broad ligament) 
(DrBrewis) ....... 190 


Fibrous Tumour of Ovary, which had been wedged in pelvis, 

simulating uterine tumour ; abdominal section (Dr Barbour) . 121 

Iluptured Ovarian Cyst, with pseudo-myxoma peritonei (Dr 

Barbour) ........ 121 

Ovarian Tumour (cyst), removed by abdominal section from a 
patient who had been operated on by Thomas Keith nineteen 
years before (Dr Brewis) . . . . . . 141 




Meeting I.— November 14, 1906. 
Dr J. W. Ballantyne, President, in the Chair. 

I. The Treasurer {Dr Wm. Craig) made his Annual State- 
ment, which is given below : — 


Balance from Session 1904-1905, 

Arrears, . . . . 

Bank Interest on Deposit Receipts, . 

Interest on Consols, . 

Entrance Fees from 28 new Ordinary- 

Annual Contributions from 380 Ordinary 

Composition for Life-Membership from 
Four Ordinary Fellows, .... 

Transactions sold, 











£563 6 2 

174 16 11 

£738 3 1 


Corporation Duty, 

Income Tax, 

Shorthand Reporters, 

Commission to Collector, 

Doorkeeper's Salary, . 

Oliver & Boyd's Account for Vol. XXXI 

of Society's Transactions (550 copies)^ 
Oliver & Boyd's Account for Printing 

Billets, Postages, etc., 
Bent of Rooms and Carriage of Books, 
Waterston & Sons' Account, 
The Secretaries and Editor, for Postages, 
Blocks for Illustrations, 

Balance to New Account, 1 

£0 10 




11 11 

1 13 

1 16 

102 12 


30 3 

5 2 

11 9 



8 2 


£173 15 2 
564 7 11 

£738 3 1 

i Of this Balance, the sum of £250, 10s. 6d. is invested in 2£ per cent. Consols. 



The accounts were audited by Dr Nicholson and Dr Dewar, 
and found correct. 

Dr Freeland Barbour, seconded by Dr Lamond Lackie, moved 
a hearty vote of thanks to the Treasurer, which was unanimously 

II. The Society then proceeded to the election of Office- 
bearers for the present Session, and the President announced 
the result as follows : — President, Dr J. W. Ballantyne ; Vice- 
Presidents {Senior), Dr Berry Hart ; {Junior), Dr Wm. Fordyce ; 
Treasurer, Dr Wm. Craig ; Secretaries, Dr Lamond Lackie and 
Dr Barbour Simpson ; Librarian, Dr Haultain ; Editor of Trans- 
actions, Dr Angus Macdonald; Members of Council, Dr»K T. 
Brewis, Dr Munro Kerr, Dr Freeland Barbour, Dr Haig 
Ferguson, Sir Halliday Croom, Dr Samuel Sloan (Glasgow), Dr 
Macrae Taylor, Dr Scott Carmichael. 

III. The following gentlemen were elected Ordinary Fellows 
of the Society :— E. Burnet, B.A., M.B., Ch.B., 4 Fingal Place, 
Edinburgh; A. S. Walker, M.B., Ch.B., Ashleigh, Middles- 
borough; Archibald Dunlop Stewart, M.B., L.E.C.S.E., 8 
Brougham Place, Edinburgh ; Henry F. Gordon, M.D., L.K.C.P. 
& S.E., 178 Colony Street, Winnipeg, Canada; E. A. Elder, 
M.A., B.Sc, M.B., Ch.B., 6 Torphichen Street, Edinburgh; E. 
W. Dyer, M.B., Ch.B., c/o Messrs Webster, Steel & Co., 5 East 
India Avenue, London, E.C. ; W. T. Smith, M.B., Ch.B., Linwood, 
Midcalder; Arnold Davies, B.A., M.B., Ch.B., Menai Bridge, 
North Wales ; T. Graham Brown, B.Sc, M.B., Ch.B., 3 Chester 
Street, Edinburgh; John B. M'Morland, M.B., Ch.B, 19 
Merchiston Gardens, Edinburgh; W. 0. Sclater, B.Sc, MB., 
Ch.B., 16 Warrender Park Cresent, Edinburgh; A. G. K. 
Ledger, M.B., Ch.B., Tupsley, Hereford; F. T. Greig, LE.C.P. 
& S.E., (Lt.-Col. E.A.M.C., retired), 16 Melville Terrace, Stirling; 
Duncan Lorimer, B.Sc, M.B., Ch.B., 7 Gillsland Eoad, Edinburgh ; 


Chas. Kobert Mitchell, M.B., Ch.B., Koyal Maternity Hospital, 
Edinburgh; W. D. Osier, M.B., CM., 11 Montgomery Street, 
Edinburgh ; Dr J. Halley Meikle, 44 Morningside Drive, Edinr. 


By J. W. Ballantyne, M.D., F.R.C.P., F.R.S. Edin., Lecturer on Mid- 
wifery and Gynaecology, Surgeons' Hall and Medical College for 
Women, Edinburgh; Physician to the Royal Maternity and 
Simpson Memorial Hospital, Edinburgh, etc. 

Ladies and Gentlemen, Fellows of the Edinburgh Obstetrical 
Society, — "To inaugurate," said Dr Johnson, in that famous 
Dictionary of his, means " to begin with good omens," or simply 
"to begin." His worthy follower in the art and science of 
lexicography, Dr James A. H. Murray, in that marvel of patient 
research and brilliant scholarship, the New English Dictionary 
on Historical Principles, after quoting Johnson's early definition, 
proceeds to amplify and lead out the meaning of the rich and 
suggestive word inaugurate in this manner : " to begin (a course 
of action, period of time, etc., especially of an important 
character) with some formal ceremony or notable act; to com- 
mence, enter upon, to introduce, usher in, to initiate." And 
then our fellow-countryman, with that dry humour which breaks 
out now and then even in his Dictionary, places within brackets 
the following additional definition: "inaugurate, sometimes 
merely grandiose for begin." Now I feel grateful to Dr Murray 
for so slyly slipping that bracketed addendum into his already 
full page; for I see, with relief, that I can shelter myself 
behind it, and can plead that if this address fall short of being 
a worthy, a notable, and an auspicious ceremonial act at the 
commencement of this, the sixty-eighth session of our Society's 
history, it can at least claim to be, beyond any cavilling, a 


A valedictory address naturally enough concerns itself with 
what is past, and has a ring of finality and farewell in it, vale ! 
vale! sounding out from it with pathetic cadence; but an 
inaugural address looks forward to the future and dwells upon 
it, not without hope and expectation of the good and great 
things that are to come out of it, for at the very heart of the 
word inaugural lies the root augur, and the augur had, of all 
men, to be always looking forward. The Eoman augur was, as 
we remember, or, as Dr Murray will tell us, if we have forgotten, 
" a religious official whose duty it was to predict future events 
and advise upon the course of public business, in accordance 
with omens derived from the flight, singing, and feeding of birds, 
the appearance of the entrails of sacrificial victims, and other 
portents." Now, although the primary visual image thus con- 
jured up can hardly be said to reside any longer in the derivative 
words inaugural, augury, and august ; although, also, the augur 
himself, with his staff and auspicial rites, has long since passed 
into the thick mists which cover even the brightest phenomena 
(and he was not very luminous ever) of a bygone age, uttering 
his vale ! yet the augural spirit is not dead in these days, but 
is as living and insistent now as it ever was during all the 
centuries which have elapsed since man first began to ask 
questions about himself and his future. In vulgar form it is 
seen in the irresponsible and sensational sisterhood of the lady 
palmists, the crystal-gazers, and the Sibylline vendors of wonder- 
working remedies and charms. It assumes scientific shape in 
the daily forecasts of the weather to be expected in these islands, 
although it must be owned that the meteorologist, being limited 
to observations made upon the surface of the earth, and having 
no stations high up among the clouds, sometimes fails as com- 
pletely in his foretelling as does the itinerant gipsy. In our 
own profession we seek, in a legitimate and proper fashion of 
course, to pierce the veil which hides the future from us, and 
we have recourse to the bacteriologist with his opsonic index 


and Widal test, to the histologist with his methods of cyto- 
diagnosis and differential blood-counts, and to the cryoscopist 
with his osmotic and ionic actions. 

There is, in a sense, the would-be augur in us all; and, 
having now in hand the giving of an inaugural address, I 
bethought me that I also might try to play the augur's part and 
endeavour to forecast the future of obstetric theory and practice. 
If I fall far short of what you may expect ; if I fail to please 
even myself (as is indeed very likely) ; if the manner and form 
of the forecasting be contrary to the traditions of Inaugural 
Addresses in learned societies ; if, in striving not to be dull, I 
become extravagant ; and if, in seeking to restrain fancy I run 
the risk of being prosaic; then let the blame rest upon the 
etymologies which have led me into such difficult territories, 
and please let it be remembered that after all "inaugurate" 
may be only "grandiose for begin." 

In Touch with the Future. 

I suppose that it was one evening in the autumn that the 
events I am going to relate apparently took place. I had, I 
fancy, been reading about some of the marvels of modern 
psychology, had been learning how a personality can be 
dissociated (on paper at least), had been grasping, with some 
difficulty, that the ego is not one but two or three, and had 
been trying, without entire success, to understand the mysteries 
of the subliminal and the supraliminal. Then I had begun to 
wonder what subject I should choose for an inaugural address 
to the Society which had so highly honoured me by placing me 
in its Presidential Chair. I was not finding the question one 
which admitted of easy solution. My mind, in freakish fashion, 
began to hunt ideas, starting a new one every few minutes, and 
chasing it until another idea suddenly emerged from the sub- 
conscious somewhere of brainland and engaged its attention. 


The house was very quiet, and my thoughts wandered on, 
undisturbed by any extraneous interruptions, save the occasional 
fall of a cinder into the fireplace, or the coming of a sort of 
breathless bark from my dog, enjoying doubtless the exciting 
pleasure of a subconscious chase after some old enemy. Suddenly 
the telephone gave one of those undecided, apocopated, monosyl- 
labic tinkles that we usually leave unanswered, and regard as 
due to a fault in the apparatus or an error of the operator. 
On this occasion, however, I put my ear to the instrument and 
whispered " Hullo ! " To my surprise an answering " Hullo ! " 
very faint and distant, but quite distinct, came back. "Who 
are you ? " I asked. 

" One nine four nought," was the reply. 

" Thank you," I said, " but I don't want to know your number ; 
I wish to know who you are, and where you are ringing up from." 

" I am not ringing up from anywhere," said the voice ; " you 
are on the Time Exchange, and until you grasp that notion 
firmly you cannot understand who I am." 

" I beg your pardon," I exclaimed in great surprise ; " I have 
heard of many Exchanges, but never of the Time Exchange." 

" That I can quite well believe," replied my unknown cor- 
respondent. "It was only on rare occasions that you in the 
beginning of the Twentieth Century got switched on to the 
Time System instead of the Place System ; you happen to have 
been attached to-night, and I thought I might venture to ring 
you up and have a talk. So, now do you know who lam?" 

" I am really very sorry," I replied, " but I haven't an idea." 

"I thought you might have guessed," he said. I am an 
officialof the Edinburgh Obstetrical Society, and the time from 
which I am ringing you up is one nine four nought, or, if you 
prefer it, nineteen hundred and forty, the Centenary year of the 
Society's existence. You are not forgetting," he added, "that 
our Society was born in 1840, having been conceived, so to say, 
in the last month of 1839." 


For the moment I was too surprised to answer this startling 
communication from the future; but I soon recovered myself 
and made a suitable reply to the Centenary Official's remark. 

The Future of Obstetrics. 

The next question that came to me over the wires stimulated 
my curiosity and determined the course of our conversation: it 
was, " Now, is there nothing you would like to ask me about 
obstetrics in 1940 ? " 

" If you will let me get my thoughts gathered together," I 
replied, " there are hundreds of questions I should like to ask 

"I do not promise to answer them all," replied Nineteen 
Forty as I may call him, " for there are some matters which I 
could not make plain to you without a great deal of preliminary 
explanation, and we have not time for that ; but I will do what 
I can to satisfy your curiosity." 

" What sort of preliminary explanation do you mean ? " 

"Well, this simply : Obstetrics has not been the only subject 
of study in which there have been advances and discoveries ; 
there have been great changes in surgery, still greater ones in 
medicine, and a revolution in physics and physiological and 
pathological chemistry ; it would require a series of lectures to 
bring your general knowledge of these matters up to the level 
required for the perfect understanding of all that has been 
accomplished in obstetrics." 

" I fully grasp the situation," was my reply. " I am now in 
a position similar to that in which an old friend of mine found 
himself in 1906 : he had been in Central Africa for fifteen or 
twenty years, and he came back to his native land to find the 
pathologists speaking the (to him unknown) language of bac- 
teriology. He had the greatest difficulty in making up leeway, 
and indeed never quite succeeded in doing so." 


"You are really in a worse state than he was," said Nine- 
teen Forty, " but I shall try to make things as simple as I can." 

Teaching of Obstetrics. 

" Being a teacher," I now said, " I should like to hear about 
your methods of conveying obstetric information in the year 

"Ah," said my correspondent, "you were, as perhaps you 
suspected, on the eve of great changes in your teaching methods 
in the year 1906. You were under the intolerable burden of 
having to give fifty or one hundred hours of purely theoretical 
teaching in order to fulfil the requirements of the examining 
boards. You delivered, each day, a lecture of an hour's length, 
containing usually a bald statement of a number of facts dis- 
coverable in almost any reputable text-book upon the subject ; 
you occasionally tried to relieve the weariness and monotony of 
your exposition by a passing reference to a specimen or a 
diagram, or by the introduction of an anecdote or a personal 
experience ; you adopted a didactic or a grandiloquent style, or, 
worse still, you read slowly and closely from a bulky bundle of 
manuscript notes. You occasionally put forceps on to the doll 
in the phantom, but you lectured all the time, and you expected 
your students to be taking down your words in their note-books, 
when you were directing their attention to the movements of 
your hands in the act of inserting the blades of the instrument. 
All this was altered at once when in the University and College 
Eegulations the words 'hour's instruction' took the place of 
' lecture ' ; instead of having to give fifty or a hundred lectures, 
you were asked to supply fifty or a hundred hours of obstetric 
instruction, a very different thing, as you can imagine. Of 
course some lecturers preferred to go on in the old way, and 
they were at liberty to do so; but many chose to vary the 
methods which had been in vogue. Here, for instance, is a plan 


which was adopted not so long after the time at which you now 
are. Each student was supplied with a neatly printed and 
fairly full statement of the subject of demonstration to be 
taken up on the following day ; to this were attached two or 
three blank sheets for the noting down of additional facts, for 
the drawing of a few diagrams, or for the indication of the page 
or pages in a large text-book where full details might be found. 
Having perused this syllabus or epitome the night before, the 
student came prepared to follow and appreciate the teaching his 
teacher was ready to give him. It might take the form of a 
demonstration of pelvimetry in normal and malformed pelvises. 
On a number of tables were several models of the well-formed 
and the deformed pelvis, with callipers of various kinds lying 
beside them. The teacher at first gave a very concise and clear 
statement of the measurements of the diameters in the normal 
and in the abnormal pelvis, and of the bearing which these 
measurements had upon labour, and indicated the various ways 
in which the diameters could be estimated. The class then 
broke up into sections for the application of principles which 
had been enunciated; and, supposing there were a hundred 
students, ten men went to each of ten tables, and tested the 
methods and familiarised themselves with the apparatus. On 
another day the demonstration would consist of the examination 
of a large number of slides under microscopes, illustrating the 
appearances of placentas from two months up to the full term, 
or of the uterine musculature at various stages of development. 
On another day the electric phantom would be brought into 
action. " 

" I beg your pardon," I here interjected ; " what was the 
electric phantom ? " 

" It was a skilfully made model of the abdomen and pelvis 
with the full-time uterus inside. By a somewhat complex 
apparatus, a doll representing the foetus could be expelled from 
the interior through the canals, exhibiting in its progress the 


whole mechanism of labour. The rate could be regulated to a 
nicety, so that a twelve hours' or a twelve minutes' labour could 
be imitated; further, the process could be interrupted at any 
stage (when the head was on the perineum, for instance), and 
the details explained. A student could be placed in charge of 
the phantom labour at any time, the most favourite being of 
course the period of vulvar dilatation and of the passage of the 
head ; if he made any mistake in the method he adopted for the 
delivery of the head and for the safety of the perineum, he 
could be checked and shown the right plan. By the touching 
of a button the pelvis could be narrowed at the inlet or outlet, 
or be deformed in other ways, and by the use of dolls of 
various sizes, representing mature, premature, and post-mature 
foetuses, different kinds of delay or varieties of mechanism could 
be exhibited. The dolls' heads were so constructed as to permit 
the occurrence of moulding." 

"I can quite understand the value of teaching such as 
you describe," I said to Nineteen Forty; and I suppose it 
was supplemented by clinical instruction in the Maternity 

" That, of course," was the reply, * and also at the various 
small maternity sub-centres, scattered over all our large cities. 
They were sets of two or three rooms, with accommodation for ten 
or twelve patients, under the charge of an assistant obstetric 
officer and one or two nurses ; in them normal or nearly normal 
cases were confined, leaving the central institution for the com- 
plicated and operative labours. But these were comparatively 
early changes in our teaching methods," went on my informant ; 
" others soon followed. One, for instance, was the introduction 
of the kinematograph and the gramophone. By a perfecting of 
the methods of obtaining differential radiograms, it became 
possible to represent internal processes, such as the passage of a 
stone down the ureter, or of the infant through the passages, by 
the kinematograph. The pictures thus obtained were thrown 


upon the screen and utilised in the teaching of obstetrics ; in 
this way, for instance, the mechanism of labour could be shown 
and the somewhat cumbrous and uncertain electric phantom 
replaced. By the gramophone we were able to reproduce and 
illustrate the cry of the parturient woman in the different stages 
of labour, and the various sounds made by healthy, by premature, 
and by semi-asphyxiated infants, as well as by those whose 
birth had been accomplished by the use of forceps. The different 
kinds of movement made by the foetus in utero (rotatory, 
calcitrant, vibratory, or singultant) could be shown by the kine- 
matograph, while the neophone reproduced accurately the fcetal 
heart sounds and the uterine bruit." 

" Stop ! stop ! " I said, " I cannot follow you any further in 
your novelties of obstetric teaching." 

" I was afraid you would begin to find there were difficulties 
in understanding all the details," was my friend's reply, " and 
yet I have only begun to name some of the new methods 
invented by science for the imparting and for the testing of 
obstetric knowledge. I was going on to tell you of the micro- 
kinematograph, by which all embryological processes and 
organogenetic readjustments could be first represented and 
then reproduced upon the screen for teaching purposes. I 
intended then to give you an idea of the automatic and 
registering gramophone for use at oral examinations, which 
excluded all conscious and unconscious bias in the testing of 
candidates for degrees, for it rolled out questions in an ex- 
pressionless tone of voice, and recorded without feeling the 
answers given in reply ; and I was hoping to have interested 
you in the great development of clinical teaching which took 
place soon after 1906, and more especially after an examination 
in Clinical Obstetrics was insisted upon by nearly all universities. 
Perhaps, however, it would be well if I passed on to some other 
subjects, for, after all, the advances in the clinical teaching of 
Midwifery were already indicated and could be recognised and 


foretold by any thinking and observant man, even at the time 
at which you are." 

Obstetrical Societies. 

" What, then, may I ask, have you to tell me about our own 
and kindred societies in the Twentieth Century?" was the 
next question which I put to Nineteen Forty. 

"There was a great and beneficial change in the life and 
activities of the various learned societies in Edinburgh soon 
after 1906. By means of a munificent gift from a wealthy 
man with strong scientific leanings, a large central hall to 
serve as a meeting-place for all the Edinburgh societies was 
built. Our own Society was, of course, one of these. But 
this was found to be a suitable occasion for a rearrangement 
of the energies and spheres of the different learned bodies, 
and so gyntecology was united with surgery to form a large 
surgical society, the Obstetrical Society devoted itself entirely 
to midwifery, the Medico-Chirurgical Society became the Koyal 
Medical Society by fusion with the old undergraduate organisa- 
tion bearing that name (the surgical members of both allying 
themselves with the newly formed surgical society), and the 
Pathological Club increased its membership and instituted 
Anatomical, Physiological, and Psychological Sections. Similarly, 
the other scientific societies rearranged themselves. Each 
society had its own afternoon or evening in the month ; but, in 
addition, there were conjoint meetings on special occasions, 
when, for instance, the Medical, Surgical, and Obstetrical 
Societies would unite together for the discussion of subjects in 
which each had an interest. The Eoyal Society was, as it 
were, the mother of us all. Through the benefactions of the 
generous donor already mentioned, the fee for membership was 
made quite a nominal one, and the member's ticket admitted to 
all the meetings, but it only conferred powers of contributing 
to or speaking at one of the societies and at the conjoint meet- 


ings in which that society took part. The most wonderful 
part of the hall of the societies was the phonograph room ; at 
least it will seem so to you," said my friend, Nineteen Forty. 
u This room," he continued, " was in telephonic communication 
with all the learned societies in the world, and if you wished to 
hear the papers read at different places you had only to switch 
yourself on to any one you might choose. In this way, you 
missed none of the asides and interruptions which are so often 
the very soul and life of a discussion. Furthermore, the 
speaker, knowing that his words were audible all over the world, 
was very careful as regards his statements, and rarely claimed 
priority for any suggestion, therapeutic or otherwise." 

" But what about understanding the language in which the 
discussion was taking place ? " was the question which I could 
not prevent myself from here asking. 

"You surely do not think for a moment that the world, 
and especially the scientific world, was content to go on till 
1940 without adopting a universal language," was the answer 
I received to my question ; and I was so taken aback by the 
tone of reproach in my friend's voice that I had no remark 
ready, and so lost my opportunity of finding out what the 
universal language was. Before I had time to recover myself 
I found that Nineteen Forty was beginning to describe to me 
some of the changes which had taken place in the practice of 
midwifery, and as I did not wish to miss anything of what he 
was saying, I had to give him my attention, 

Obstetric Practice. 

" You must know," he was saying, " that the discovery 
which revolutionised obstetric practice in the twentieth 
century was that of a tocophoric serum." 

" What was that ? " I asked. 

"A serum obtained from the blood of pregnant animals 
which had been treated with cultures from the blood of a 


human placenta, obtained preferably from a case of placenta 
praevia," was the reply. " Its introduction into use gave us 
the means of safely, speedily, and certainly inducing healthy 
action of the .uterus. In this way a labour could be brought 
on and a child born with almost the same degree of certainty 
with which it used to be possible to perform a surgical opera- 
tion. The day, and in some cases even the hour, could be 
arranged, and a midwifery case became a certain part of the 
day's work instead of an uncertain contingency in the middle 
of any night. In the nineteenth century the introduction of 
anaesthesia abolished the pains of labour and brought in a 
new era of obstetric advance; in the twentieth century the 
discovery of this tocophoric serum did away with the 
uncertainty of the supervention of labour, and had an almost 
equally great influence upon our subject. The profession 
earned the gratitude of countless patients, who said something 
like this : ' In the past you relieved our pains and sent us to 
sleep in the midst of our agony; but now you have released 
us also from the intolerable bondage of our uncertainty, and 
we thank you for this new boon.' Post-mature confinements, 
with their risks and delays, were in this manner done away 
with ; a time suitable alike for patient, nurse, and obstetrician, 
and calculated as accurately as possible to coincide with the 
full term of pregnancy, was fixed upon; and the labour was 
conducted with the same care and aseptic precautions as a 
gynaecological or other operation." 

" But what about premature labours ? " was the question 
with which I here checked my friend's flow of description. 

"I expected that remark," was his reply. 'You must 
know that the special investigation given to the pathology 
of pregnancy in the early part of the twentieth century bore 
good fruit in the discovery of means of successfully preventing 
the premature termination of pregnancy, and such abnormal 
labours became very rare. At the same time the tocophoric 


serum gave us a means of interrupting pregnancy, when for 
medical or obstetric reasons (such as pelvic contractions, heart 
disease, etc.) it was regarded as desirable so to do." 

The Falling Birth-Kate. 

"But the great principle of obstetric practice in the 
twentieth century," continued my informant, " was the securing 
of the safety of the infant." 

"You mean," I said, "that the falling birth-rate forced 
obstetricians everywhere to reconsider all their methods, 
operative and otherwise, from the standpoint of the life of 
the infant ? " 

"Yes, indeed," was the reply; "and I shall now try to 
make this plain to you. I must introduce some statistics to 
bring out my meaning, but you, of course, can take your ear 
from the instrument if you are bored." 

" Truly, I shall do no such thing," I protested. 

"In 1906 the falling birth-rate in our own and in all 
civilised lands was at length beginning to attract the attention 
it deserved. The birth-rate for England and Wales was 35*2 
for the decade 1865-1874; it was 347 for the next decade; 
for the next period of ten years (1885-1894) it had fallen to 
31'2; and during the last ten years (1895-1904) it has sunk 
to 29*0. So much for England and Wales. Sir Henry 
Littlejohn had a still more depressing account to give of 
the capital of Scotland. In 1871 the natality in Edinburgh 
was 34*8 (almost the same as that of England and Wales at 
the same time) ; in 1881 it was 32'2 ; in 1891, 28'2 ; in 1901, 
24-99; and in 1905 it was 22-99. 1 Even with these figures 

1 The figures for 1906 are now available : the number of births was 
7042, and the birth-rate was 22'41 per 1000. The descent, therefore, 
is steadily going on, and the number of babies born in 1906 is actually 
less than the number in 1881, although the population has so greatly 


before you the full gravity and meaning of the position was 
not recognised in 1906. In order to grasp the significance of 
the movement, look at the matter thus. In 1881, when the 
population of Edinburgh was (in round figures) 228,000, the 
number of babies born was 7360 ; in 1905, when the population 
had increased to 336,000, the number of babies born was 7741, 
whereas, if the rate had been maintained, it ought to have been 
10,846. There was therefore a shortage of over 3000 babies. 
It is only fair to the country in general to state that Edinburgh 
occupied almost the worst position in this matter of a falling 
birth-rate. Of the sixteen large towns of England and 
Scotland, there was only one (Bradford) that had a lower 
birth-rate than Edinburgh; and while London registered 27, 
Dundee had 28, Manchester, Birmingham, Aberdeen, and 
Leith had 29, Glasgow and Greenock had 30, and Liverpool 
had 33." 

" But," I here interruped, as my friend paused to note the 
effect of these undeniably startling figures, "the death-rate 
had fallen as well as the birth-rate, and so we were no worse 
than we were before." 

" Let us take the Edinburgh statistics again," was the reply. 
"In 1881 the death-rate was 1886; in 1905 it was 1425, the 
lowest ever reached till then. While, however, the death-rate 
was slowly falling from 18 to 14, the birth-rate had come 
rapidly down from 32*23 to 22*99. If this rate of descent had 
in each case been maintained for another quarter of a century 
the two rates would have reached almost the same figure, and 
any increase in the population of Edinburgh would have had 
to be put down to immigration, for the birth-rate had been 
falling much more quickly than the death-rate. Further, while 
it was conceivable that the natality of Edinburgh would 
continue to fall till it reached a vanishing point, it was 
not thinkable that its mortality would do likewise. There 
might come a year when there were no births, but it could 


hardly be expected that in that year there would occur no 
deaths. All these things, however, were to the inhabitants of 
Edinburgh in 1906 as idle tales; they heeded them not. And 
yet, to Edinburgh obstetricians at least, the subject of the 
falling birth-rate was a grave problem, and it became no 
less grave as the twentieth century proceeded on its way. To 
put the matter very practically," said Nineteen Forty, "there 
were many more doctors settled in Edinburgh in 1906 than in 
1881, but the number of babies being born. was practically the 
same. I expect some of you had shrinking lists of midwifery 
engagements to deplore, but I forbear to press the point." 

" Can you give me now any hints as to the way in which 
obstetricians in the twentieth century met the dangers of the 
falling birth-rate ? " was my next question. 

"That I will gladly do," was my friend's answer; "but, 
first, I must point out what perhaps was little recognised or 
altogether overlooked in 1906. I refer to the aggravations of 
the falling birth-rate." 

The Aggravations of the Falling Birth-Kate. 

" What were these aggravations ? " I asked. 

"In the first place, there was the infantile death-rate. 
You were proud, in 1906, of the fall that had taken place in 
the general death-rate of the country during the preceding 
half century, and your pride was justified; for there had 
been a reduction by more than fifty per cent, of the number 
of deaths between the ages of five and twenty-five years, 
and between twenty-five and thirty-five there had also been 
a notable decrease. But there was one circumstance about 
which little was said, and about which no pride could be felt : 
the infantile death-rate was practically unchanged at the end 
of these fifty years of hygienic progress and material advance- 
ment. To quote from the Report of the National Conference 



on Infantile Mortality (p. 99), held in London in June 1906 : 
'In the twenty years ended 1874, we find that out of every 
1000 children born alive in England and Wales, 153 never 
completed their first year, while in the twenty years ended 
1904, the ratio was 148 per 1000.' There was, it is true, 
a slight improvement — 148 instead of 153 — but was it an 
adequate, a satisfactory, even a noteworthy degree of improve- 
ment, when contrasted with the fifty per cent, improvement 
between the ages of five and twenty-five? This, then, I 
call the first aggravation of the falling birth-rate : fewer babies 
were being born, and yet they were dying off practically as 
rapidly during the first year of life as they had ever done. 

"A second aggravation was your ignorance, in 1906, of 
the stillbirth-rate and the abortion-rate of your country. You 
did not know how many pregnancies ended in the birth of 
infants who never lived outside the mother's uterus, who, 
in the words of one of the nineteenth century poets, exchanged 
c the amnios-skin of this world for the shroud, the amnios- 
skin of the next.' You hoped, perhaps, that fewer stillbirths 
were happening, but you dreaded lest your hopes should turn 
out ill-founded ; at any rate you did not know, for there was 
no registration of stillbirths to reveal the frequency of 
such ante-natal catastrophes. In reality, a steady increase 
was going on, as Dr Kaye's Yorkshire statistics, local though 
they were, proved. He found that in 1901 there were 47*6 
stillbirths per 1000 livebirths, and the number steadily 
increased until in 1905 it was 56*3. 'Apply these figures/ 
said Dr Kaye {Report of the National Conference on Infantile 
Mortality, 1906, p. 104), 'to the whole country (England and 
Wales), and it means that the number of stillbirths has grown 
from 44,270 in 1901 to 52,350 in 1905, an increase of over 18 
per cent., while the total livebirths have decreased in actual 
numbers/ Then as to the abortion-rate, you must surely," 
said the Official of 1940, '' have had some feelings of dismay 



when, in 1906 and in preceding years, you reflected upon the 
wastage of ante-natal life by reason of abortions. You could 
hardly shut your eyes to and stop your ears against the 
testimony of text-books and journal articles which, with 
striking unanimity, attested the frequency, the growing 
frequency, of abortion. Some placed the frequency of mis- 
carriage at one to every three or four pregnancies; others 
stated that one in every five gestations ended in abortion." 

Here I interrupted my informant with the remark that 
I did not think the abortion-rate was so high as that. 

" What reasons have you for doubting it ? " 

"Well," was my reply, "in the last series of 100 indoor 
labours under my care in the Edinburgh Eoyal Maternity 
Hospital there were not many women who gave a history 
of having aborted." 

"But," said my friend, "did you exclude the primiparas 
and the women under thirty years of age ? " 

" No," I replied. 

" Suppose you do that ; how do your statistics stand now ? " 

"In the 100 cases there were 21 women of thirty years of 
age and over, and of them 8 gave a history of previous 

" There you are," said Nineteen Forty in triumph ; " thirty- 
eight per cent, of your patients who had reached the middle 
of reproductive life had aborted ! Besides," he continued, 
"you had only the patients' word for the number of their 
abortions; it is much more likely that they under-estimated 
than over-estimated the frequency of such occurrences, especially 
early miscarriages of six weeks. You must, after all, admit 
that not fewer but more abortions were occurring in Great 
Britain in the early years of the twentieth century. There 
was yet another aggravation to the falling birth-rate, to which 
I must, for a moment, refer. That was the curiously significant 
increase in the number of deaths ascribed to premature birth 


which began to be noticeable in the mortality returns. The 
infantile mortality from premature birth, which in 1865-1874 
was 11-9 per 1000 (for England and Wales), had in 1875-1884 
grown to 13-7, in 1885-1894 to 168, and in 1895-1904 to 198. 
The most striking thing about this increase was that it began 
as soon as and no sooner than the birth-rate commenced 
to decline. One can hardly refuse to ascribe some significance 
to that fact. 

"Now, let me gather together these various statements," 
said Nineteen Forty, "and you will see better how you really 
stood in the year in which you are living. The infantile 
death-rate, notwithstanding all recent advances in hygiene 
and the laborious study of the diseases of infancy, was no 
better than it was fifty years previously. There was reason 
to believe that the number of stillbirths and abortions 
was increasing; and these, although they constituted deaths 
in a real sense if not in a forensic one, were not included 
in the mortality tables. The number of infantile deaths 
ascribed to premature birth was increasing, pointing to a 
probable increase in the total number of premature births 
occurring. Finally, there was the progressive and serious 
fall in the birth-rate. What could the obstetricians of the 
twentieth century do but strive to counteract these evils ? " 

Checking the Falling Birth-Eate. 

" How did they check the falling birth-rate ? " was my 
question, for my informant at this stage in our conversation 
seemed to expect me to say something. 

" They did not check it, they could not check it," was 
the startling reply; "but they checked the aggravations 
of it, and so secured some salvage from the wreckage of 
life which was occurring before, at, and immediately after 
birth. This salvage more than compensated for the decline 



in the birth-rate, and thus the civilised nations of the earth 
were able to maintain their position to some extent, at any 
rate, if not entirely. So now you see why I so strongly 
emphasised the aggravations of the falling birth-rate. But 
matters got much worse before they began to improve." 

" In what way ? " I asked. 

" I will tell you," was the reply. 

" The checking of the falling birth-rate was, as I have said, 
not an obstetrical problem at all ; at least it was not one which 
obstetricians could hope to solve. The falling of the birth-rate 
was not due to less knowledge or less skill in the obstetricians 
of the day, or to want of training of the midwives and monthly 
nurses, or to the neglect of chloroform or the forceps, or to 
the excessive use of these means of relieving pain and hastening 
the second stage of labour, or, indeed, to any other thing which 
lay in the power of the medical man to do or leave undone. 
The causes lay deep among the roots of the somewhat artificial 
conditions of the sexual relationships in modern society. A 
nineteenth century writer (Kenan) said : ' The spread of an 
enlightened selfishness is, in the moral world, a fact of the 
same nature as the exhaustion of coal-fields in the physical 
world; in each case the existing generation is living upon 
and not replacing the economies of the past.' His words 
apply very exactly to the enlightened selfishness which was 
the root-cause of the falling birth-rate. The era of personal 
comfort first, and at any cost ; the age of late marriage, because 
the entrants upon the matrimonial state wished to begin, not 
where their parents began, but where they were prepared to 
leave off; the period of frequent holidays and expensive 
amusements could hardly be described as other than ' selfish/ 
although it might be doubted whether it deserved the honour 
of being entitled ' enlightened.' In any case, such an age was 
not one in which frequent child-bearing was likely to be 
thought of with favour, or carried through with enthusiasm. 


If there was ergophobia in the one sex, there was maieusophobia 
in the other. Nor was a popularisation of the knowledge 
of the nature and mode of use of ' checks ' to conception likely 
to raise the average size of families. 

"Matters did not improve after 1906. In fact, it was not 
long till rumours began to circulate regarding the existence 
of a new institution, the ' City without a Child,' a sort of 
municipal agennesia, wherein mental productivity and financial 
success were held in high esteem, while the reproduction of the 
race was nothing accounted of. The inhabitants renounced the 
pleasure and the honour of having families, but gladly accepted 
all other pleasures and honours that came in their way. The 
citizens occupied their days in making money, and their nights 
were not spent round the fireside in the home. They were 
described as curious places, these experimental childrenless 
cities : no schools, no toy-shops, no Christmas-trees, no happy 
young boys and girls on the roadways; nothing but hard- 
visaged men and steel-eyed women, and bustle and racket, and 
vain hopes and restless desires; and by-and-by an alarming 
increase in the frequency of suicide, and in the number of the 
inmates of the palatial asylum which stood upon a hill 
overlooking the town. So, in the end, the attempt to reduce 
the birth-rate to nil was the cause of its gradual ascent again ; 
and the experiment of race-suicide was in that sense a failure. 

"In the meantime the medical profession, and especially 
the obstetricians, had been busily endeavouring to save some- 
thing from the wastage of ante-natal life, and to keep alive 
many of the new-born infants who formerly used to succumb 
to death in various forms during the first few months of post- 
natal existence." 

Estimation of the Wastage of Ante-natal Life. 
"In the first place," continued the Official of 1940, "the 


obstetricians of the early part of the twentieth century set 
themselves the task of estimating the annual loss of life at 
and before birth. With the help of a Stillbirth Eegistration 
Act, and with the assistance of the army of skilled monthly 
nurses which the Mid wives Bill had called into being, statistics 
of stillbirths and abortions were obtained. The results were 
startling, appalling in fact; but after the first excitement 
incident thereupon had died down, it was seen that in the very 
magnitude of the loss of ante-natal life that had been going on 
lay the hope of the future. By diminishing the ante-natal 
death-rate, by checking the frequency of abortion, it was 
recognised that there was a means ready to hand to counter- 
balance the falling birth-rate. If a fifth of the stillbirths and 
abortions could be prevented, it was seen that the loss accruing 
from the smaller number of births would be compensated. 
Further, it was discovered that many of the cases which went 
to produce the high infantile mortality of 148 per 1000, during 
the first year of life, were deaths of prematurely born infants. 
So it became apparent that to check the frequency of premature 
births would give a means of reducing the high infantile death- 
rate; in this direction also there lay compensation for the 
failing birth-rate. You can almost forecast for yourself now 
the lines along which obstetric practice began to advance," said 
my friend of 1940; "but I will indicate them very briefly." 

Study of Pregnancy, Normal and Pathological. 

" The hygiene of pregnancy began to be studied in detail and 
with an enthusiasm and thoroughness never before arrived at. 
Patients were encouraged to consult their medical attendants 
regarding the rules of health in pregnancy, and the latter were 
prepared to give the advice sought. It was recognised that 
pregnancy was a severe and a long-continued testing of the 
structural and functional integrity of all the organs of a 


woman's body. It was soon seen that while an unmarried or 
a non-pregnant woman might with impunity, or apparent 
impunity, break many of the laws of hygiene, a pregnant 
patient did so at her peril ; and every medical man made it his 
duty to revise with the pregnant patients all the rules relating 
to the care of the bodily functions, putting right what was 
wrong, and warning against possible errors in diet, clothing, 
habits, and the like. 

"Further, in cases of doubt, consultations were freely asked 
for and given, it being recognised that it was better to check 
the beginnings of evils in pregnancy than to wait till an 
abnormal gestation had developed into a labour dangerous for 
infant and mother alike. Whereas in your time," said my 
informant, " consultations in pregnancy were seldom asked for, 
save to determine whether the induction of abortion should be 
carried out in order to try to save the mother's life at the 
expense of that of her foetus, in the new era the specialist was 
called in early enough for his remedial measures to avail both 
the maternal and the infantile lives. In this way, not only 
were pathological pregnancies often prevented altogether, but 
in many instances they were so energetically treated in the 
early phases that they yielded to therapeutic means that would 
have been of no use at later stages. Eclampsia was one of the 
first of the gestational maladies which began to benefit by such 
a revolution in the management of pregnancy. Whereas it had 
been common for the urine of a pregnant patient never to be 
tested — indeed, in many cases it was not customary for the 
medical attendant to be told about the pregnancy or summoned 
to the patient till labour was in the first stage — now, the doctor 
was engaged to look after his patient in the early weeks of her 
pregnancy as well as in the hours of her labour and in the days 
of her puerperium. His duties included regular analysis of the 
urine, as well as the supervision of all the details of the gesta- 
tion, and the correction of any of the symptoms which might 



arise. The obstetrician of 1940 finds it difficult to understand 
why his brethren of the early part of the century paid so much 
attention to the one month of the puerperal period and so little 
to the nine months of pregnancy. To him the time of pre- 
paration for labour was not less but more important than the 
time of recovery from the effects of labour, for he found that if 
the former was normal the latter was little likely to be 

" Along with this development of the study of the manage- 
ment of pregnancy and of the treatment of the disorders of 
the pregnant state came a marked advance in the knowledge of 
ante-natal maladies. The mystery of trans-placental trans- 
mission was elucidated, and stillbirth by reason of foetal diseases 
and defects became rare. So-called 'habitual' abortion and 
intra-uterine death were soon shown to be due in every instance 
to some definite and ascertainable cause ; and the hopelessness 
which had previously characterised all attempts at treatment 
gave way to the enthusiasm inspired by frequent success. 
New and more effective means of keeping prematurely born 
infants alive were adopted with the best results, and the 
favourite British operation of the induction of premature 
labour for contracted pelvis took an enhanced position of 
esteem among other methods of obstetric intervention. As I 
have already said, the appreciation of the value of foetal life 
was the fact which dominated obstetric theory and practice in 
the twentieth century. Embryulcia, craniotomy, and all such 
destructive procedures yielded to methods which gave a chance 
of survival to the child, and thus Cesarean Section, Vaginal 
Section, and the Induction of Premature Labour took their 
rightful place in the list of obstetric operative measures. By 
means of the knowledge which obstetricians gained regarding 
the state of their pregnant patients {eg, by pelvimetry, 
physical examinations, etc.) it was possible to detect pelvic 
contractions, tumours, and the like before the supervention of 


labour, and so to avoid interference at the time when the 
occurrence of the phenomena of childbirth was the cause of 
additional risk and danger. For instance, it became rare for 
a medical man to be summoned to a full-time labour in which 
there was an undetected pelvic contraction, and thus, emergency 
Cesarean Sections or (worse still) craniotomies were hardly 
ever heard of." 

The Problem of Cancer. 

" I have greatly benefited by what you have told me," I said 
to Nineteen Forty; "but can you satisfy my curiosity about 
one other matter ? It is scarcely an obstetric problem, perhaps, 
but it is a very pressing one : I refer to the discovery of the 
cause and cure of cancer." 

" I cannot reveal much," was the reply, " but I am permitted 
to throw out some hints. For instance, it was not long after 
1906 that it came to be recognised that there was a curious 
parallelism between great philanthropic movements and note- 
worthy life-saving and pain-relieving discoveries." 

" What do you mean ? " I queried. " Well, take the case of 
the abolition of slavery in the British possessions at a cost of 
£20,000,000 ; that was a great and a beneficent and an unselfish 
act on the part of one section of mankind for the amelioration 
of the condition of another and a suffering section ; it was soon 
followed by the discovery of anaesthesia — that priceless boon. 
Of course, the anaesthetics themselves had been in existence for 
years, but their effects were till then unknown." 

"I think I see what you mean," I said; "and was there 
any great philanthropic advance pending in 1906, or soon there- 
after, which made it possible for the discovery of the cause 
and cure of cancer to take place as a corollary thereto ? " 

My friend hesitated a little before he replied, and then said 
slowly: "The greatest boon that mankind could voluntarily 



bestow upon itself would be the abolition of war, would it 
not ? " 

" You think," said I, " that it was that great international 
blunder — the appeal to arms to settle disputes — that was 
delaying the discovery of the cure of cancer ? " My informant 
did not answer this question; at least, if he did, I, in my 
excitement, failed to catch his reply. So I went on and said 
to him : " I myself have of late years been inclined to look to 
the chorion-epithelioma and its embryological relations for the 
elucidation of the problem of the origin of malignancy ; but I 
have a friend who believes that the secret lies in the hands of 
the botanists. He is sure that in the differences of the life- 
conditions of fungi and bacteria are to be found the explanation 
of the origin and the theory of the cure of cancer." 

" Tell him to make experiment," was the reply which came 
to me somewhat indistinctly, for it appeared as if my telephone 
were not recording very clearly. I spoke again, but it seemed 
as if the connection had been cut ; so, as I did not wish to be 
rude, I asked for the Time Exchange, No. 1940, and got 
switched on again. " I wished to thank you very warmly for 
so kindly giving me so much information about the future," 
I said. u Can you answer one other question, a personal 
one ? " I asked. " You described yourself at the beginning of 
our conversation as an Official of the Obstetrical Society of 
1940 ; can you give me no other clue to your identity? " 

" I am the President," was the reply. 

" Indeed, then," I said, " I am highly honoured, sir, to have 
made your acquaintance." 

I heard what sounded like a laugh, and then this rejoinder 
came back to me over the wires : " You call me sir, but is it 
impossible that the President of 1940 should be a woman ? " 

I awoke with a start, to find my telephone ringing furiously ; 
and a call to a serious case at the Maternity Hospital was soon 
engaging my thoughts. But I have sometimes wondered 


whether it was all a dream; whether it was not in part an 
" uprush of the subliminal consciousness/' as the psychologists 
call it ; whether it was not, in certain details, a vision of that 
future so rapidly advancing upon us, when — 

Much that is wrong shall be righted, 
And man shall see, never affrighted, 

Clearly his duty, and do it, 

E'en if his life-blood go to it. 

On the motion of Br Ritchie, seconded by Br Craig, a hearty 
vote of thanks was unanimously accorded the President for his 


By J. Lamond Lackie, M.D., F.R.C.P. Ed., Assistant Physician, Royal 
Maternity Hospital ; Lecturer on Obstetrics and Gynaecology, 
School of Medicine of the Royal Colleges. 

Until quite recently, I had been in the habit of thinking, 
and indeed sometimes of teaching, that when the obstetric 
forceps slipped off the head during the operation of extraction, 
the instrument had been unskilfully applied. "Within the last 
month I have changed my views on this point entirely. Up 
till October of this year I had no personal experience of the 
accident, but during that month I had two consecutive cases 
in which the forceps slipped, and these form the basis of the 
present communication. 

Case I. — Mrs D., set. 29, primipara, went into labour on 
Thursday, 4th October, at 2 A.M. The pains at first were slight 
and very occasional, but the membranes ruptured at 10 A.M. ; 
and at 11 A.M., when I first saw her, the os was only the size 



of a shilling. It dilated very slowly, and little progress was 
made all Friday. During the night the pains were stronger, 
and at 10 a.m. on Saturday the os was 3 inches in diameter, 
and a right occipito-posterior position was diagnosed. Pains 
were strong till 3 p.m., but on examination one found that 
since 10 a.m. absolutely no progress had been made, and the 
anterior segment of the cervix had become oedematous. At 
4 p.m. the patient was exhausted, and inertia uteri had set in. 
Chloroform was administered, and the dilatation of the os 
completed by the fingers. Forceps were then applied to 
the head, which was well engaged in the pelvic inlet. Strong 
traction seemed to make no impression, and suddenly, during 
an extra effort on my part, the forceps came away in my hands. 
The sensation, to say the least of it, was unpleasant ; one felt 
that one had fractured or dislocated something, but I take it 
that the click one feels and hears is simply due to the sudden 
excessive overriding of the cranial bones which the closed 
forceps causes as the instrument comes over the head. For- 
tunately, the damage to the mother's soft parts was slight, but 
the vulva was somewhat torn by the escaping forceps. I then 
tried to flex the head and rotate it, but, as I almost expected, 
my efforts were fruitless, as the head was too high up and too 
fixed. Forceps were again applied, and appreciating the fact 
that the occiput was to the back, I endeavoured to apply the 
blades in that region. Again the forceps slipped when I 
pulled, and this not once but several times. The instrument 
was not each time forcibly pulled out of the vagina, as I was 
always on the outlook for slipping. Here, I may say, that by 
grasping the application handles, as well as the traction handle, 
I was better able to appreciate whether the blades were to 
slip or not; one seemed to be more in sympathy with the 
position of the blades by sensation conveyed through the 
handles than through the traction rods. Ultimately, one 
seemed to find a grip that held, well back over the occiput, 


and the head was born face to pubis, but only with great 
difficulty, and after the expenditure of much force in traction. 
There was some laceration of the perinseum. The child, a 
female, which weighed 9 lbs., was apnceic, but recovered, though 
it showed signs of compression for two or three days. It is 
now very well, but has a marked internal strabismus of the 
right eye, which, however, is now improving. The mother had 
a normal puerperium. I ought to mention that she was a 
woman of average stature, and there were no obvious signs of 
any deformity of the pelvis. This, then, was simply a per- 
sistent occipito-posterior case, delivered in the usual way by 
forceps — the only peculiarity being the slipping of the forceps, 
which shows how excessive was the traction necessary for 
delivery. I have quoted the case as a contrast to the two 
which follow. 

Case II. — Mrs W., set. 30, ii.-para, expected her confinement 
on 10th October, but this did not take place till 28th October. 
Pains commenced at 2 a.m. ; at 4 A.M., when I saw her, the os 
was nearly but not quite fully dilated. Eight occipito-posterior 
was the position. At 5 A.M. the membranes ruptured and the 
liquor amnii began to trickle away. The cervix was still not 
fully taken up. At 8.30 a.m. there was no change, except that 
the anterior segment of the cervix had become oedematous. 
Pains were now slight, and made no impression on the advance 
of the head, which remained at the brim. Under chloroform, 
forceps were applied, and, to my surprise, I repeated my 
experience of 6th October. The forceps came away in my 
hands with, fortunately, no damage to the mother. I reapplied 
them, still remembering the position of P.O. P., but the result 
was the same, and no matter how carefully I applied the 
instrument well back towards the promontory of the sacrum, 
the forceps, whenever traction of any degree was employed, 
came over the head with that click which is so suggestive of 



serious injury to the child. I applied the forceps no less than 
six times, but I could not get the head to enter the pelvis. I 
then tried to turn the child's head round so that the occiput 
should be to the front, and at the same time I endeavoured to 
turn the shoulders by external manipulation; but though I 
could move the head I could not turn the shoulders, and 
before I could get the forceps applied the head was back to its 
original position. Finally, I introduced my hand past the head, 
and with two fingers on the right shoulder and my left hand 
acting through the abdominal wall, with great ease I turned the 
child round till it occupied the L.O.A. position. Once more 
I applied the forceps, and with comparatively little traction 
the child was born within three minutes. It weighed 10 J lbs., 
but seemed to have suffered no injury except facial paralysis, 
which passed off in three days. The mother had a normal 
puerperium. She was a woman of medium height, and had 
no pelvic deformity. I delivered her of her first child exactly 
four years previously, when the labour was almost normal, 
forceps being applied only to bring the head over the perinaeum. 

Case III. — I hoped I had done with difficult E.O.P. cases 
for the month, but I was mistaken. On Tuesday, 30th October, 
at 10 a.m., I was called to Mrs B., iii.-para, who had been in 
labour since 4 a.m. The os was the size of half a crown. At 
3 p.m. the liquor amnii began to trickle away. At 5 p.m. the 
os was nearly, but not fully, dilated ; the position was E.O.P. , 
and the head was high up and movable at the brim. At 9 p.m. 
there was no change, and inertia uteri had set in. The patient 
was chloroformed, and first of all I applied forceps, but the 
locking was so unsatisfactory that I was not surprised that 
traction proved useless, and I therefore soon desisted. Eemem- 
bering my experience of two days before (Case II.), I determined 
to try internal rotation of the head. I removed the forceps, 
then pushed the head upwards, and by internal and external 


manipulation turned the head round till the vertex lay in the 
RO.A. position. A pain came on and fixed it there, and as 
rapidly as possible I applied the forceps. Extraction was 
quite easy, and a living child was born, 9 lbs. in weight, with 
no signs of damage at all. The interesting point about this 
case was that the patient had been confined twice before, nine 
years ago and seven years ago, and on both occasions she was 
very ill, instruments were used, and both children were born 
dead, having died, the mother tells me, during birth. I cannot 
help thinking that but for artificial internal rotation the result 
would have been just the same on this occasion. 

The first and the second and the third cases which I have 
narrated form a striking contrast. The first was a primipara 
who presented all the usual features of a malposition of the 
head — a slow first stage, premature rupture of the membranes, 
and oedema of the anterior segment of the cervix, which one 
notes seems in these cases always to hang free in the pelvis 
between the head and the outlet. The second stage was 
delayed, the descent of the head was only partial, spontaneous 
rotation did not occur, the forceps slipped several times, but 
ultimately the patient was delivered simply by excessive 
forceps traction. Had forceps failed, one had to think of 
craniotomy, symphysiotomy, or pubiotomy. The second and 
third cases presented the same preliminary feature as Case I., 
but the head was still movable at the brim. There were several 
possibilities of treatment had forceps ultimately failed — 
Cesarean section, embryulcia, etc. — but the whole object of 
this paper is to emphasise the fact that to rectify a malposition, 
if diagnosed early, is possible and sometimes easy. I have 
rarely been so struck with the effects of treatment as in the 
second case, where what proved almost an intractable case 
became quite suddenly, by simply rotating the child, one of 
the easiest high forceps cases I have ever experienced. The 


child was large, it was post-mature, but once it was placed 
in a normal position it was delivered in a very few minutes. 
Before resorting to a more serious obstetric operation, such as 
craniotomy, I should certainly have performed internal version, 
which is generally recommended in these cases, but the chances 
for the child would then have been much diminished. Every- 
thing was no doubt favourable for artificial rotation : the head 
was still not properly engaged, the liquor amnii had not all 
escaped, and the patients were multiparas. Since in nine cases 
out of ten an E.O.P. rotates so that the occiput comes forward, 
one would not attempt this operation if the head were descend- 
ing with the pains ; one would simply further rotation chiefly 
by increasing flexion. In all text-books reference is made to 
artificial rotation of the head when it has reached the pelvic 
floor, and this is common practice ; but only in a few, and these 
are foreign, is rotation when the head is high up recommended 
as a possible method of treatment. I am not sure that in this 
country the value of artificial rotation of the whole child when 
the head refuses to enter the pelvis has been duly appreciated. 
Under the circumstances which prevailed in Cases II. and III., 
I should be inclined, if an E.O.P. were diagnosed early, to again 
try artificial rotation, rather than risk a very difficult forceps 
case — a possible sacrifice of the child by version, or a certain one 
by embryotomy. 

Br Barbour was much interested in Dr Lackie's communica- 
tion, which drew attention to a method of dealing with occipito- 
posterior cases which was not sufficiently recognised in this 
country. It was noteworthy that the head was delivered with 
much greater ease, lying in the same diameter, with the occiput 
to the front instead of to the back, because the difficulty was 
evidently in this case not in the longer rotation the head had 
to undergo, but in some cause interfering with its engagement, 



or with proper flexion. The cause of deficient flexion in 
occipito-posterior positions was not evident. It had been 
ascribed to the promontory, but this explanation was not 
adequate. He congratulated Dr Lackie on his successful 
management of these cases. 

Dr Haig Ferguson cordially thanked Dr Lackie for his 
interesting and suggestive paper. All present, no doubt, had 
had experiences such as Dr Lackie's in the slipping of forceps 
in occipito-posterior cases. In his opinion, this slipping was 
due to the head being extended and the forceps grip being too 
near the sinciput and not sufficiently far back on the head. 
This could be rectified by promoting flexion of the head by 
manual manipulation, after which the forceps can generally be 
applied satisfactorily without fear of slipping. When the 
forceps is applied when the head is extended, traction simply 
tends to keep up, if not to increase, the extension, and so the 
delivery of the head is not by any means facilitated even when 
the blades do not slip off the head. He was much interested 
to hear that by an apparently comparatively simple manoeuvre, 
as Dr Lackie described it, a right occipito-posterior position, 
as in Case II , was converted even into an L.O.A. He would 
certainly try this method of artificial rotation the next 
suitable opportunity he had, as it seemed not only rational, but 
eminently calculated to conserve fcetal life, a point so strongly 
and rightly insisted on by the President in his address just 

Dr James Ritchie felt indebted to Dr Lackie for having 
reported cases showing the ease with which in posterior 
positions, under suitable conditions, the body of the child could be 
rotated. Kotation of the head alone was not satisfactory. He 
thought that the chief reason why delivery was more difficult 
in posterior than in anterior positions lay in the fact that, 
in consequence of the projection of the promontory there is less 
room at the posterior end of the oblique diameter than in front, 



and that the sinciput, being smaller, passes more easily than 
the occiput. 

Br Dewar thanked Dr Lackie for his eminently practical 
paper. Papers such as the one read were a great help to the 
practitioner in his everyday life, inasmuch as they refreshed 
the memory by recalling some of the principles in the treat- 
ment of difficult cases, which are apt from infrequent application 
to become dim in the mind. In thinking over those occipito- 
posterior positions, one or two thoughts had occurred to him. 
A medical man was sometimes called to a labour case at a very 
early stage. It was very customary for him, after making the 
usual vaginal examination and finding the os undilated or only 
very slightly dilated and the passage dry, to heave a sigh, perhaps, 
if it should be three o'clock in the morning, and tell the patient 
and her friends that, as labour was hardly commenced, he 
would go home, and come back in the morning. He confessed 
that he used to follow such a practice, but experience had 
taught him to adopt a different method, which he had now 
practised for many years. By being content with a simple 
vaginal examination the medical man missed his best opportunity 
of rectifying an abnormal position if it should be present. His 
routine practice was, if the os was undilated, to make an abdominal 
palpation, as he was anxious to find out, if possible, what presenta- 
tion and what position he had to deal with. It was easy to read 
in the text-books what to do in difficult cases, but it was not so 
easy in practice ; yet, with patience and a little care, if such an 
opportunity occurred, it was fairly easy, by palpation, to make out 
whether the presentation was a transverse, a breech, or an 
occipital one. If occipital, he should try to satisfy himself 
whether the position was occipito-anterior or occipito-posterior ; 
if the latter, he should then endeavour to rectify at once, as it is 
very much easier to rotate the child at that stage, when the 
membranes were still intact, than at a later stage, when the head 
was engaged in the brim or in the pelvic cavity. If, however, 


the case was not seen till at a later stage, he favoured internal 
rotation by the hand rather than by the forceps, as being less 
dangerous to both mother and child. He narrated the difficulties 
of an occipito-posterior case, in which the persistence of the 
position was probably due to the tip of the coccyx projecting 
forwards at a right angle to the sacrum, and thus diminishing 
the antero-posterior diameter of the pelvic outlet to something 
like 3| inches, which was certainly too little to allow the passage 
of the occipito-frontal diameter of the head, which would be 
at least not less than 4J inches. The position remained a 
persistent posterior one, in spite of all his endeavours to rectify 
it, and while attempting to deliver with forceps, a snap was 
heard, after which the head was extracted in the ordinary way 
of K.O.P.'s. The coccyx was fractured. In the patient's 
second labour the same difficulty occurred, the coccyx having 
united at a similar angle. On this occasion, profiting by the 
experience of the previous labour, he forcibly fractured the 
coccyx with his fingers, so as to avoid damage to the occiput, 
which was present in the first labour, and delivery was com- 
paratively easy. On the third occasion, with the tip of the 
coccyx in the natural position, the position was an R.O.P. again, 
which very soon rotated into an anterior position, and the 
child was born without assistance, showing that the peculiar 
position of the coccyx in the first two labours was the cause of 
the failure of rotation. With regard to the question raised by 
Dr Barbour, as to why the head, when rotated from the posterior 
to the anterior position, should engage in the brim more easily, 
Dr Dewar thought that an answer would be found in the fact 
that after rotation above the brim, the belly of the child would 
adapt itself to the concavity of the uterus and pelvis behind, 
the spinal column would curve correspondingly, and the occipito- 
spinal joint coming behind the line of the uterine force, flexion 
would take place, allowing the head to pass easily through the 
pelvic inlet in the wide oblique diameter. 


Br Church joined in the expression of indebtedness to Dr 
Lackie for his practical and suggestive paper. He referred to 
the danger of injury to the maternal parts over and about the 
region of the ischial spine from pressure of the child's head 
in occipito-posterior positions. Sloughing and septic troubles 
might supervene from such injury. He had read Professor Sir 
Halliday Croom's paper on this subject, and had been impressed 
with the importance of this point. He had met with an 
illustrative case in his own practice. He expressed the opinion 
that in all great lying-in institutions a detailed account of 
every presentation should be recorded in the case books. This 
would add to their scientific value. For example, "Vertex" 
was not enough. The particular vertex presentation should be 
defined, and so on. In connection with occipito-posterior 
positions, it would appear (from the Talmud) that the 
ancient Jews were of opinion that most female children were 
born in this position. Hence a medical reason for the longer 
puerperium of the mother and the longer Levitical period of 
ceremonial uncleanness. By kind permission, he had looked 
at the books of our own Maternity Hospital and found that 
there were considerably more female than male occipito-posterior 
positions. Obstetricians of to-day could generalise like the 
Eabbis of old, but, like them, they still found in occipito-posterior 
positions possible conditions of danger and difficulty. Dr Lackie 
had shown us how to lessen the difficulty. 

Br Oliphant Nicholson thanked Dr Lackie for his interesting 
paper, and wished to make a few remarks regarding the 
management of difficult occipito-posterior labour. He had had 
quite an abnormal number of such cases recently in his dis- 
pensary practice, and these positions of the head seemed to be 
commoner than was generally supposed. Occipito-posterior 
labour might be easy or difficult ; if it was really difficult, it 
constituted one of the most undesirable and dangerous complica- 
tions due to malposition of the foetus — a presenting shoulder 


was infinitely more easy to deal with successfully. There were 
several methods of management, in these cases, and he had 
tried them all. He thought everyone who had had a large 
experience in this kind of case, would agree that the manual 
rotation of the child's head and body into the correct position 
was the best. It was the most scientific treatment, and it was 
also the best for the safety of mother and child. He would 
like to mention some of the methods commonly adopted, and 
briefly discuss their application to certain cases. 1. First, there 
was delivery by the forceps without any attempt to correct the 
position of the head. This was probably the commonest 
method of all, because the general practitioner did not always 
trouble to diagnose the position of the head. If a labour was 
lingering, and the head did not descend, forceps were applied, 
and the doctor pulled — often with his utmost strength — till the 
child's head appeared at the vulva. Most of these cases were 
persistent occipito-posterior ones. Sometimes rotation of the 
child's head occurred during traction, especially when axis- 
traction forceps were used, but generally the occiput emerged 
behind. Now, even when one knew that the position of the 
head was occipito-posterior, this method was sometimes good 
practice. Eobert Barnes had advised it, and when the head was 
relatively small, and one had not to exert dangerous traction, 
the delivery was generally safely completed without extensive 
perineal laceration. 2. A slight modification of this method was 
gradual rotation of the head carried out by the forceps during 
traction. The blades were removed and re-applied several times 
till rotation was completed. This method was applicable to 
those cases where the head showed indications of rotating 
during traction; the application of the blades two or three 
times was the important thing to complete rotation. 3. The 
next method was the manual rotation of the head alone to 
carry the occiput behind the pubic arch. It was then held 
in its new position and forceps applied. In applying this treat- 


ment it was necessary to know that the case was an occipito- 
posterior one, and he had to confess — after fifteen years' 
experience — that he could never be certain of this point by 
means of fontanelles and sutures. In every case where the 
head remained high up and would not descend, he made a very 
thorough vaginal examination. With the patient well over on 
her left side and under chloroform, the whole of the left hand 
was passed into the vagina and the fingers pushed over the 
head until an ear was felt. In occipito-posterior cases an ear 
was always easily reached; that point by itself was rather 
suggestive of the position. But this method he had found 
excellent, inasmuch as it not only verified the position, but 
indicated the direction in which one should rotate. One always 
rotated away from the ear. This method of correcting the 
position of the head by means of the hand was, as a rule, very 
easily carried out. He always used the left hand, and the 
head, being firmly grasped, was lifted up right out of the pelvis 
between the pains. The manoeuvre was often carried out with 
extraordinary ease; sometimes, however, it was very difficult, 
and then one must adopt some other means of effecting delivery. 
The main objection to this method was that, unless the body of 
the child was rotated at the same time, the head had a great 
tendency to spring back to its old position. Thus it was 
always necessary, after rotating the head in this way, to keep 
one's hand on it, and apply the forceps with the other hand. 
He wished to mention the advantage, in such cases, of introduc- 
ing the upper blade first ; after the application of this blade, the 
head could be kept in position while the lower blade was 
introduced. He might mention also the advantage of the 
axis-traction forceps with straight blades — such as Milne- 
Murray's — for these cases, because with them a better grip of 
the head over the parietal bones was obtained; the ordinary 
curved blades were certainly more apt to slip off the head 
during traction. When the forceps were got on to the head in 


its new position and traction was made, the body of the child 
swung round ; the neck of the child did not break. 4. The 
best method of all was manual rotation of both the head and 
the body of the child. The body was rotated through the 
abdominal wall by placing the right hand behind the shoulder 
and pressing it forwards, this being done at the same time as 
the left hand in the vagina rotated the head. In some cases 
this was easily done, but in others very great difficulty was 
experienced in getting the body of the child round. Most 
practitioners had met with these troublesome cases, and the 
natural thing was to pass the hand still further into the uterus, 
in order, if possible, to get the body to rotate. Last year, in an 
exceptionally difficult case of this kind, Dr Nicholson, in passing 
the hand higher up, came upon the child's shoulder, and grasped 
it within the uterus. Then rotation was accomplished with 
surprising ease. He was much impressed at the time with 
this method, and he had no doubt that others who had dis- 
covered the manoeuvre had been similarly impressed. On 
looking up the literature of the subject, he found that it had 
been described, and advocated to the exclusion of all other 
methods, by Professor Mcllwraith of Toronto, in a paper 
published in the Canadian Practitioner and Review of February 
1905. He did not know whether others had described the 
manoeuvre ; but it was certainly one that deserved to be more 
widely known, and Dr Lackie had brought the matter pro- 
minently before them in his excellent paper. 

Dr Lackie, in reply, said that it was to him quite remarkable 
how easy the children were delivered after artificial internal 
rotation at the brim. In the first case he had converted an 
E.O.P. into an L.O.A. ; in the second he managed to rotate the 
head only to the E.O.A. position, which, however, was quite 
sufficient. When it was possible, rotation of the whole child 
was preferable to mere rotation of the head. He thanked the 
Society for the kind way in which they had received his paper. 


?i^» j> . . 

[Tnset at page 41. 


Meeting II.— December 12, 1906. 
Dr N. T. Brewis, Vice-President, in the Chair. 

I. The following gentlemen were elected Ordinary Fellows 
of the Society :— D. Lloyd Koberts, M.D., F.K.C.P., 11 St John 
Street, Manchester; J. S. Edwards, M.B., Ch.B., University 
Union, Edinburgh. 

II. Dr Brewis showed— (a) Two examples of endothel- 
ioma of the ovary, removed from a patient aged 20. Miss 
McK., admitted September 1906; complaining of swelling 
in the lower abdomen and pain in that region when she turned 
herself; duration two months. She had always had pain at 
her periods, but since January 1906 that pain had been more 
severe. She had strained herself at that time by lifting a 
very heavy weight. Two months ago, when an attack of pain 
had come on after turning herself in bed, she felt a hard lump 
the size of a marble on the right side of her lower abdomen. 
This grew gradually larger. A short time after she had 
noticed the first swelling, she felt another on the left side of 
the lower abdomen. This also gradually increased in size, 
but she thought it was softer to the feel than that on the 
right side. On admission, an irregular mass was filling the 
hypogastric and lower part of the umbilical region. Menstrua- 
tion regular, twenty-eight-day type; duration, seven days; 
quantity fairly copious ; pain present. Operation. — Abdominal 
section, double ovariotomy; small quantity of free fluid in 
abdomen. Pathological Report. — Extracts from Mr Muirs 
letter : — " The condition is that of lymphatic endothelioma, but is 
undergoing extensive colloid degeneration. The sections from 
different parts of both the right and left ovaries show that the 
structure is much the same in all. The essential tissue 
element is seen to be made up of endothelial cells arranged 
in a very indefinite manner, but in parts one can make out 


these cells to be lining lymphatic spaces, and some spaces 
are filled with cells forming an alveolar-like structure. The 
stroma in parts is well denned and at others scanty. The 
areas showing an open network of delicate stroma forming 
spaces, are really the tumour cells undergoing colloid degenera- 
tion ; in parts their condition is more advanced, showing 
complete transformation of the endothelial cells into colloid 
material; only the stroma persists." Patient went home 
feeling quite well, on the thirty-second day after operation, 
having made a splendid recovery, only interrupted by a fainting 
turn on the eighteenth day after operation. 

(b) Bare variety of dermoid tumour, tuberculous tubes, 


B., set. 24, admitted 8th October 1906, complaining of pain 
in the right side, distension of the abdomen, and occasional 
pain in the left side. Duration of illness, four years ; symptoms 
more marked during the last year. Menstruation regular, 
twenty -eight-day type ; duration, two to three days ; flow less 
in quantity since onset of pain in the right side a year ago. 
On opening the abdomen a large grey- walled cyst was exposed, 
and through parts of the wall of the cyst small yellow bodies 
like coriander seeds could be seen floating about in the interior 
of the cyst. The cyst was tapped, clear, straw-coloured fluid 
and little yellow bodies escaping; the cyst was then removed 
without any special difficulty. In the situation of the right 
ovary was a body, yellowish in colour, and in shape and size 
like a medium-sized horse-chestnut. This was adherent to the 
omentum, and had to be dissected from dense adhesions to the 
lower end of the caecum. The fimbriated extremity of the 
right tube was attached to this body, and was swollen. 
The left tube was distended in its outer third to the size of a 
pigeon's egg. A round yellow body the size of a pea was 
attached to the fimbriated extremity. The left ovary was 
hard and cirrhotic looking. Under the left ovary and parietal 


peritoneum, covering the left wall of the pelvis, was a cyst 
firmly adherent to the wall of the pelvis. The patient, although 
very sick and much pained for some days after the operation, 
was making an uninterrupted recovery. 

(c) Dermoid tumour of the ovary, which ruptured during 
administration of the anaesthetic : — Miss R, age 28, admitted 
2nd November 1906. Complaint. — Distension of the abdomen ; 
duration, a fortnight. Some little pain in September 1906 ; 
frequency of micturition at the end of October, with a little 
fulness of the lower part of the abdomen. During the next 
ten days the abdomen gradually became distended, till on 
the day of operation it had reached the size of a six months' 
pregnancy. While the anaesthetic was being administered, 
the swelling disappeared, the abdomen becoming quite flat. 
On opening the abdomen, greasy fluid, fat, and hair welled 
up into the wound. A dermoid cyst about the size of a foetal 
head was found, with a rupture in the cyst wall about 2 inches 
long. This cyst, a dermoid of the left ovary, was removed. 
The right ovary was slightly enlarged, and cystic. The 
abdomen was thoroughly washed out, but great difficulty was 
experienced in getting rid of all the fatty material. After 
the operation the pulse kept very fast — over 100 — and twenty- 
four hours after the operation the patient became very 
restless. On the morning of the second day she was slightly 
delirious. The same day a condition of stupor developed. 
This gradually deepened; her pulse remained between 100 
and 130 ; her respirations were at times deep, with long pauses 
between, but never stertorous, and she died on the third day 
after the operation. The wound was opened on the day of 
her death, and there was no sign of peritonitis. The tempera- 
ture the day after the operation was 99° F. ; the day before her 
death it was subnormal, and remained so till just before her 
death, when it rose to 102° F. 

(d) Euptured ovarian tumour, presenting microscopic 


characters of adenocarcinoma and tubercle : — Mrs A., age 53 ; 
admitted 22nd October 1906; married twenty-eight years; 
widow twelve years; six children. Complaint — Swelling on 
the right side of the abdomen, with a continuous sore 
feeling in that region. Patient had reached the menopause 
two years before. Between that time and six months ago, 
she noticed that a swelling was present on the right side 
of the abdomen. This part then became tender, and had 
remained so since. Six months ago a red discharge like 
that at her periods set in, and lasted six weeks. Since then 
this discharge had returned at irregular intervals, being 
usually very copious, and sometimes had an unpleasant odour. 
It was sometimes clotted. She had had pain in the right side, 
and an uncomfortable bursting sensation for the past six 
months. Her husband and one child died of consumption. 
A large firm mass filled the left iliac, left lumbar, lower part 
of umbilical, and left side of hypogastric regions. A dull note 
in the flanks changed from side to side with the altered 
position of the patient. Operation. — On opening the abdomen 
a large quantity of free fluid escaped. The omentum was 
found adherent to the tumour. The intestines were roughened, 
red, and extensively studded with tubercles Ovariotomy 
was performed. There was considerable bleeding and oozing. 
Everything in the pelvis was very friable, and bled easily. 
The left ovary was a normal senile one, and was not removed. 
Pathological Report. — The tumour had the appearance of a 
columnar -celled carcinoma. The specimen also consisted in 
parts of granulation tissue infiltrated with leucocytes, and 
presenting advanced necrosis, so that its features suggested 
the probability of tuberculosis. Patient got up on the twenty- 
first day after operation, having made an uninterrupted recovery, 
and went home a week later, feeling and looking quite well. 

(e) Uteeus with large cervical fibroid, removed at the 
fifth month of pregnancy. The abdomen was opened, and the 



foetus, which was not viable, was delivered by Csesarean section ; 
then the uterus and large cervical fibroid which filled the pelvis 
were removed by hysterectomy. (Described in paper, page 49). 
(f) Uterus with fibroid tumour in lower uterine 
segment, removed at term by supravaginal hysterectomy after 
Ccesarean section. Mrs B., age 33. Married ten months; no 
children ; no miscarriages. History. — Patient was confined to 
bed from Easter Monday 1906 until May 1906 with severe 
sickness. When she got up she was seized by a violent pain 
in her left side, chiefly in the left iliac region. Pregnancy, 
complicated by a fibroid tumour, was diagnosed. She was kept 
in bed for seventeen weeks on account of the pain. A belt was 
then given her to wear. She got up, and had no recurrence of 
the pain. The pregnancy was allowed to go on till full time. 
When labour set in, the foetal head was found occupying the 
right side of the pelvis and a hard rounded swelling the left 
side of the pelvis, both situated just above the brim. The 
abdomen was opened, and the rounded swelling was seen to be 
a rounded mass the size of a cricket ball, in the wall of the 
uterus, at the left side of the lower uterine segment and under 
the bladder. The child was delivered alive by Caesarean 
section. The placenta was removed, and the uterus, which had 
another projection from the wall at the fundus, was removed 
by supravaginal hysterectomy. On section, the rounded mass 
was seen to be a fibroid tumour, and the cylindrical projection 
near the fundus a fibroid growth which had undergone colloid 
degeneration. Both mother and child did very well, the mother 
making a rapid recovery. (Described in paper, page 49). 

III. Br Haig Ferguson showed — (a) 1. Tubal pregnancy 
(two months), showing dilated ostium tubse, and ovum partially 
protruding. Eupture had at the same time occurred slightly 
into the broad ligament. Free blood in abdominal cavity; 
operation on account of pain, haemorrhage, and continued 


orowth of tumour. 2. Complete tubal abortion (about second 
month). Tube apparently empty, but still bleeding through 
open ostium. Pelvis full of clot, containing shreds of membrane 
of gestation sac. Operation for pain, steadily increasing 
hematocele, and symptoms of internal bleeding. In this case 
it was necessary to drain through the posterior fornix into the 
vagina, on account of the large raw surface behind the uterus, 
which was packed with gauze. Both patients made good 

(b) Large double pyosalpinx, apparently tubercular. The 
uterus was removed at the same time, to render operation 
possible. Free ends of both tubes adherent to each other 
behind the uterus. 

(c) Uterus with fundal cancer, removed by vaginal 
hysterectomy from a nulliparous patient, aged about 55. She 
complained of haemorrhage as her only symptom, and there was 
no pain. Uterus measured 2 \ inches with the sound. Curettage ; 
scrapings reported as malignant adenoma. Disease limited to 
fundus. Satisfactory recovery. Patient had weak heart, so 
the vaginal route was chosen, which, though more difficult in 
a nullipara, caused less disturbance and shock to the patient. 

(d) Chorion epithelioma of uterus, removed by vaginal 
hysterectomy. This was the second specimen of decidnoma 
malignum shown here to the Society by Dr Ferguson this year. 
The patient, Mrs 0., age 38, had an imperfect abortion, and 
was sent to hospital for curettage. Severe haemorrhage oc- 
curred after curetting ; scrapings were examined by pathologist, 
who reported chorion-epithelioma. Uterus was removed by 
vaginal hysterectomy. Good recovery. Patient remaining well 
four and a half months after operation. The former specimen, 
which he now brought for comparison, was removed in April last, 
and the patient was still in excellent health. Her age was 47. 

(e) Inverted uterus, of puerperal origin, after a carefully 
conducted labour. Insidious commencement, with practically 



no symptoms. Eecognised six weeks after labour; reduction 
impossible; vaginal hysterectomy; good recovery. (Case 
reported in full in Journal of Obstetrics and Gynaecology of 
British Empire, October 1906.) 

(/ ) Soft subperitoneal fibroid, resembling an ovarian cyst. 
This tumour was removed by abdominal hysterectomy, from 
a patient aged 60. The uterus was completely upside down 
in the pelvis, and was normal in size as measured by the 
sound. She had been treated by pessaries for a considerable 
time with no benefit. The symptoms were constant bladder 
irritation, and pelvic pressure symptoms. When Dr Ferguson 
saw the patient he thought the tumour alongside the uterus 
was an intraligamentous cyst in close contact with the right 
side of the uterus. Even after removal the examination of 
the specimen gave that impression, so soft and fluctuating was 
the mass. The patient made a good recovery from the operation, 
and her distressful symptoms had quite disappeared. 

(g) Chart showing ante-partum temperature of 105-8° F. 
(malarial), when child was born alive. The patient, a primi- 
para, made a good recovery, and the child did well. Labour 
was to have been induced prematurely on account of a narrow 
pelvis. The high temperature, however, combined with the 
quinine, set the labour going just at the time the induction was 
to have been done, so no further interference was necessary. 

(h) Uterus, removed by vaginal hysterectomy, one year 
after a double pyosalpinx (probably gonorrheal) had been 
removed by abdominal section. The uterus was removed for 
persistent, purulent, and offensive uterine leucorrhoea combined 
with pain, which resisted curetting and all other minor treat- 
ment. The patient and her doctor both urged hysterectomy, 
which, owing to the shortness of the broad ligaments (the result 
of the previous oophorectomy), was a somewhat difficult pro- 
cedure. The uterus, when opened after removal, was found to 
be transformed into an abscess cavity, with rough and sloughing 


mucous surface, and containing offensive pus, penetrating down 
to and involving the muscular walls. The patient's health was 
completely re-established after the vaginal hysterectomy, and 
she described herself as an absolutely transformed woman, as 
regards her sense of well-being and comfort. 

IV. Dr Barbour Simpson showed a replica of the medal 
presented to Professor Pozzi last July by his colleagues, friends, 
and former pupils, in recognition of his position as President 
of the Seventeenth Surgical Congress, Paris, 1904, and of his 
promotion to the grade of Commander of the Legion of Honour. 
Dr Simpson mentioned that a Livre oVOr was also presented to 
Dr Pozzi at the same time, containing twenty-four original 
contributions by his colleagues, former pupils, and friends. 

V. Dr Haultain showed a specimen obtained from a 
multipara a fortnight ago. The history was that, when the 
students arrived at the case, they were told that the placenta 
had already been born. The child was born shortly after 
their arrival, and the placenta came away thereafter normally. 
On examination microscopically, the purplish mass of the 
specimen turned out to be a blood tumour formed of capillaries 
and large blood-vessels, with practically no connective tissue 
between the vessels. The whitish mass was composed of 
necrotic tissue. There was no trace of foetal structure or 
decidual cells. The mass was about the size of a cocoa-nut, and 
apparently was some abnormal product of conception analogous 
to * Foetus Ovideus." 

VI. Dr James Ritchie showed a specimen OF an early 
ovum. The last period had taken place on 4th July; the 
abortion was on 31st August ; but from the size of the ovum, 
conception must have occurred only shortly before the date of 
the period which was missed. 



By N. T. Bkewis, M.B., F.R.C.P.E., F.R.C.S.E., Gynaecologist, Royal 
Infirmary, Edinburgh. 

Cases of pregnancy complicated by fibroid tumours for which 
the operation of hysterectomy is indicated are of rare occurrence. 
I have previously reported to the Society two such cases : one 
for fibroids obstructing the pelvis and causing severe pain, the 
other for a tumour of such extremely rapid growth that it filled 
the entire abdomen in three months. I now wish to add to 
this record two further cases. In one the tumour filled the 
pelvis, and caused such severe pressure symptoms that the 
operation was a matter of urgency, and had to be performed 
during the sixth month. The other was operated on at full 
term, chiefly on account of the obstruction which the tumour 
offered to the passage, per vias naturales, of the child. In over 
1000 major operations, I have had to interfere seven times in 
this manner with fibroids during pregnancy ; ovarian tumours I 
have removed seven times during pregnancy ; and in cases of 
malignant disease in the pregnant uterus, I have performed 
Cesarean section and hysterectomy on three occasions. 

In each of the cases I now wish to record, Cesarean section 
preceded hysterectomy. 

The first case is that of Mrs C., aged 37, who was admitted 
into Ward XXXVI. in October of this year, complaining of 
great pain in the lower part of the abdomen and in the back. 
The patient last menstruated in the first week of June. The 
early symptoms of pregnancy soon asserted themselves. In 
July, trouble with micturition began — at first the act was 
painful and difficult, afterwards there was increased frequency. 
At this time also severe pain in the back set in, followed at a 
short interval by pain in the abdomen, which confined her to 



bed, and which continued until relief was obtained by the 
operation. Her menstruation began at 16, was of the twenty- 
eight-day type, and lasted three days. The amount was copious 
during the first day, and slight during the remaining two days. 
There was always pain on the first day. 

On physical examination the breasts were found to be large, 
and colostrum was easily expressed from the nipple. The 
abdomen was enlarged by a swelling which reached to the 
umbilicus. On the right side it projected markedly, and pre- 
sented the signs of a pregnant uterus. On the left there was 
felt a separate swelling of much harder consistence. Per 
vaginam, the finger felt this swelling passing down into the 
pelvis and almost entirely filling the cavity. 

The cervix was situated far forward, immediately behind 
and against the symphysis pubis. 

Pregnancy plus a solid tumour was diagnosed ; the patient 
was anaesthetised, and an attempt made to dislodge the tumour 
from the pelvis. This attempt failed however. "We were 
anxious to withhold any further interference until the child 
became viable, but the pain continued so severe and persistent 
that it was feared some degenerative change might be taking 
place in the tumour; moreover, her general condition was 
becoming each day less favourable, and to add to her misery, 
and to our anxiety, symptoms of intestinal obstruction and also 
of ureteral pressure were beginning to manifest themselves. 
It was therefore clear that we had to consider what could 
best be done in the mother's interest. With this object in view 
we determined to open the abdomen, deliver the child by 
Cesarean section, and then proceed to remove the tumour. 

A mesial incision was made from the pubis to above the 
umbilicus. On opening into the abdominal cavity the gravid 
uterus at once presented, and was, after some manipulation 
delivered through the wound. A large fibroid tumour could 
now be felt filling the pelvis. To get access to this tumour 



it was necessary to empty the uterus. To do so, a longitudinal 
incision, about 3 inches in length, was made in the anterior 
uterine wall. Through this the five-and-a-half months' foetus 
was delivered, the placenta was expressed, and the uterine 
incision sutured. It was now possible to draw the tumour 
out of the pelvic cavity, where it was found to be growing 
from the posterior aspect of the supravaginal portion of 
the cervix. Supravaginal hysterectomy was performed in 
the usual manner. The cervical mucosa was removed; the 
vaginal vault was perforated, and a gauze drain passed down 
into the vagina. The abdominal incision was stitched in layers. 
The patient made a most satisfactory recovery. 

On section, the central portion of the tumour presented the 
characteristic appearance of a fibroid, but surrounding this and 
towards the surface there was extensive degeneration. The 
tissues were much broken down, the spaces thus formed being 
filled with glairy-like substance. 

The operation just described took place on the 2nd of 
November, and on the following day Case No. II. went into 
labour, and a similar operation was performed on her, thus 
forming a notable example of the interesting phenomenon, 
which most medical men have experienced, of rare cases coming 
in sequence. 

The following are the chief points of interest in the 
history : — 

The patient, 33 years of age, has been ten months married. 
There is no history of any previous pregnancy or abortions. 

Menstruation began at 13, was regular, lasted five days, 
and, until two years ago, presented no abnormalities. For 
the past two years there has been a dull dragging pain, chiefly 
in the iliac regions and upper parts of the thighs, during the 
menstrual period. There has never been any intermenstrual 
discharge. For some time there has been increased frequency 


of micturition, but neither pain nor difficulty. Albumen was 
present in the urine. 

Patient last menstruated from the 7th to 12th February 
1906. In the latter part of April 1906 patient had severe 
sickness, and was confined to bed for two or three weeks. On 
getting up she experienced severe pain in the left side. This 
was at times agonising in its severity, and was most marked in 
the left iliac region. The pain persisted for three or four weeks, 
and then gradually became less severe. When the pain had 
subsided, the patient was examined by her doctor, who told her 
she was pregnant, and also that she had a tumour ; he kept her 
confined to bed for seventeen weeks. I saw her in consulta- 
tion at the end of August 1906, when I found her six months 
pregnant. Growing from the left side of the uterus there was 
a hard tumour, which filled the greater part of the pelvic brim. 

The patient was most anxious to have a living child, and, 
as the symptoms were now not so severe as they had been, 
we decided not to interfere until the full term. I ordered the 
patient an abdominal belt, and advised her not to remain 
in bed. The support obtained from the belt had the desired 
effect : there was no recurrence of the abdominal pain. 

The patient came into my Home on 27th October, and 
subsequent to that date was under my personal observation. 
On 3rd November she complained of pain all day at intervals ; 
this was felt chiefly in the back, and did not tend to radiate 
to the front. At 4 p.m. the membranes ruptured. At 6 p.m. 
the cervix, on vaginal examination, was found to be soft, but 
only sufficiently dilated to admit the tip of the index finger. 
The foetal head was found on the right side of the abdomen, 
above the pelvic brim. On the left side, also just above the 
brim, there was a firm rounded mass, about the size of a foetal 
head. Attached to the uterine wall, about 2 inches above 
and to the left of the umbilicus, there was a projection which, 
through the abdominal walls, felt like a foetal foot and leg. 


At 7 p.m. the patient was anaesthetised and a thorough 
examination made. The head was found -still above the brim, 
which it was prevented from entering by the tumour. The 
cervix was still undilated. As the liquor amnii had drained 
away some hours before, and the child had consequently been 
exposed to severe pressure between the fibroid and the strongly 
acting uterus, it was decided that labour should, alike in the 
interests of mother and child, be terminated as quickly as 
possible. The safest method for both was undoubtedly Csesarean 

The abdominal cavity was opened by an incision extending 
2 inches above the umbilicus. The uterus was brought into the 
wound. The obstructing tumour was found to be a fibroid 
situated on the left side of the lower uterine segment ; it was 
rounded in shape and about the size of a cricket ball. The 
projection from the body of the uterus, described above, was 
found to be an irregularly shaped subperitoneal fibroid situated 
about lh, inches internal to the insertion of the left round 
ligament. The bladder had markedly hypertrophied walls and 
was found to reach to an abnormally high level. 

The uterus was opened by an incision about 4 inches long 
in the anterior wall. Through this the child was delivered and 
the placenta removed. The uterine incision was then sutured 
with thick catgut. The tumour was next shelled out of the 
uterine wall. In spite of all efforts to promote uterine action, 
the organ remained in a relaxed, flabby condition. Owing to its 
atonic state and the consequent oozing, it was found necessary 
to perform supravaginal hysterectomy. 

The child, though small, was in no way malformed. 

Mother and child returned home well twenty-eight days 
after operation. 

Remarks. — The presence of fibroid tumours in the uterus 
may complicate pregnancy, parturition, and the puerperium in 


a variety of ways. The site which the growth occupies is the 
chief factor in determining the significance of the complication. 
For example, subperitoneal growths in the body of the uterus, 
unless of considerable size, may not give rise to any symptoms 
during pregnancy, and may not interfere with the progress of 
parturition ; while a tumour growing in the lower pole of the 
uterus may give rise to severe pressure symptoms during 
pregnancy, and may constitute a complete barrier to the passage 
of the f oetus through the pelvis during labour. An intra-uterine 
growth may interfere with the development of the product of 
conception and lead to abortion, with risks of haemorrhage and 
sepsis, or may hinder delivery, or cause post-partum haemorrhage. 
Therefore pregnancy may occur in a uterus the seat of a fibroid ; 
but such a tumour may cause no symptoms during pregnancy, 
and need cause no anxiety. Here we may leave nature to 
safely terminate the labour. On the other hand, a fibroid 
tumour may so complicate a pregnancy that not only are the 
symptoms during pregnancy urgent and severe, but its presence 
may place the patient's life in jeopardy when labour sets in. 
The cases which I have just related belong to this class. The 
first was an example of a tumour causing distress and danger 
during pregnancy, the second was an example of a tumour caus- 
ing danger during labour. When it is clear that a pregnancy, 
complicated by fibroid tumour, requires surgical treatment, it 
is possible that the case may be treated, and scientifically 
treated, by more methods than one, though, doubtless, there 
must in each case be one method better than any other. In my 
opinion, this applies to Case No. II., but not to Case No. I. 

The propriety of the treatment adopted in Case No. I. could 
not be questioned. The tumour filled the pelvis, and could not 
be dislodged ; it presented an impassable barrier to the transit 
of the child; its presence was a menace to life, and caused 
symptoms which could no longer be endured by the patient. 
The indications were so urgent, there was no alternative but to 


operate without delay in the interests of the mother. The 
only method other than the one adopted would have been to 
remove the tumour, leave the uterus, and thus give the mother 
a chance of carrying the foetus to term. This did not occur to 
me at the time, but an examination of the specimen shows that 
such a method, however ideal, was in this case impracticable. 

In Case No. II., the tumour gave rise to no urgent symptoms 
during pregnancy, and in this case our treatment was to be 
planned and carried out with the view of saving both 
mother and child, or, better still, mother, child, and uterus. 
The possible procedures that occur to me other than the one 
carried out are two in number : — 

1. Labour might have been induced at the seventh 
month and the tumour removed subsequently. Against this 
plan we have to consider the risk of the induction to the 
mother, the risk of losing the child, and the subsequent major 
operation for removal of the tumour. 

2. The tumour might have been removed without interfering 
with the pregnancy. This might have been attempted, but 
there were not sufficient grounds to ensure the successful 
carrying out of this procedure. 

As events turned out, this result would not have been 
attained without difficulty and danger. The tumour was placed 
under the bladder, was sessile, and had a broad attachment to a 
very vascular part of the uterus, and haemostasis would have 
been difficult and uncertain. The question of whether the 
fibroid uterus should be sacrificed after removal of the child 
and the tumour was considered, and decided in the affirmative : 
first, on account of the uncertainty of being able to deal satis- 
factorily with the bed from which the tumour had been 
removed ; and secondly, from the fact that the remainder of the 
body of the uterus was not healthy. I think, as events proved, 
the course which we followed was right and proper. The 
mother and a healthy child were saved, and the former returned 


home well and strong ; and, though deprived of the power of 
bearing offspring in the future, I think that, after her experience, 
she will be glad that such an event is not possible. 

Dr James Ritchie said they were very much indebted to 
Dr Brewis for having submitted these two very interesting 
cases. The class of case referred to was one of extreme gravity 
in practice. When one discovered a cervical tumour in a 
married woman, it was often a matter of great difficulty to know 
how to treat the case. Although the tumour might not be very 
large at the beginning of pregnancy, it would probably grow 
very much during pregnancy. Should immediate operation be 
recommended, or waiting? He thought Dr Brewis had put 
before them very clearly the rules for guidance in such cases. 
It would, he thought, be well to explain to the patient the 
greater danger of waiting for operation till full term rather than 
having it dealt with at a comparatively early stage of preg- 
nancy; and, having given the explanation, to allow the patient 
to choose between early operation and waiting events. In the 
first case there was no doubt about the procedure which 
should be adopted. 

Dr Lamond Lachie thanked Dr Brewis for the report of 
two such interesting cases. He said it was quite clear that Dr 
Brewis had adopted the best possible means of saving those 
patients, but remarked that it was curious how in some cases 
nature so frequently seemed to overcome difficulties that at first 
sight seemed insuperable. The most interesting case he had 
seen of pregnancy complicated by fibroid tumour was of a lady 
who had come to Edinburgh on account of a fibroid tumour com- 
plicating pregnancy, diagnosed by her doctor. Dr Lackie in 
examining per vaginam had found it absolutely impossible to 
feel any os. The pouch of Douglas was entirely occupied by 


the fibroid. It was determined to leave the patient for a time, 
and perform Cesarean section at a later date. At eight months 
labour set in, and at once preparation was made for Cesarean 
section. Labour went on very rapidly, and on examination it 
was found that the cervix had descended, and the os was lying 
practically in the centre of the pelvis, so that the fibroid tumour 
which had occupied the pouch of Douglas had risen up, and 
the head of the child presented in the normal way. After the 
birth of the child the os had ascended again, and the pouch of 
Douglas was again occupied by the tumour, and it was found 
necessary to give chloroform and hook the cervix down, pass in 
the hand, and remove the placenta. The patient made a good 
recovery, and went home with the tumour very much less in 
size than it had been during pregnancy. 

Dr Keppie Pater son asked if Dr Lackie had followed up the 
case, but Dr Lackie replied that he had not done so. 

Dr Brewis, in reply, said the case cited by Dr Lackie might 
have been a pedunculated fibroid. 


By James Haig Ferguson., M.D., F.R.C.P.E., F.R.C.S.E., F.R.S.E. ; 

Assistant Gynaecologist, Royal Infirmary, Edinburgh; Assistant 
Physician, Royal Maternity Hospital, Edinburgh j and Gynaecologist, 
Leith Hospital. 

In recent years, owing to the brilliant and rapid advances of 
surgery, the operation of nephrectomy has become no uncommon 
procedure for various diseased conditions of the kidney. It 
follows that we as obstetricians will occasionally be confronted 
with the question : Should a woman with one kidney be advised 


to marry and run the risk of becoming a mother? I am 
assuming, of course, that the remaining kidney is healthy and 
equal to its duties in ordinary circumstances. 

We know that during pregnancy in healthy women the 
kidneys undergo hypertrophic changes of a strictly physiological 
character, so as to enable them to cope with the increased work 
they have to do. In the same way, as is well known, the one 
healthy kidney in the patient whose diseased kidney has been 
removed undergoes hypertrophy, which probably began long 
before the nephrectomy was performed, the diseased kidney 
having in all likelihood been more or less functionless for a 
considerable time prior to operation. 1 If in such a case 
pregnancy should then supervene, further hypertrophy will be 
required to meet the necessary demands; and as, so to speak, all 
the patient's eggs are now in one basket, any undue strain on 
this kidney will at once mean very serious renal insufficiency. 

The case I am about to record shows that in a patient 
whose remaining kidney is healthy, and has had time to become 
sufficiently hypertrophied to perform the work of two, the 
strain of pregnancy can be fairly well borne ; for although the 
patient developed albuminuria, and had a diminished excretion 
of urea, yet when she was put on proper treatment (though it 
was somewhat late in the day) the condition yielded fairly 
satisfactorily to appropriate remedies, and the kidney irritation 
tended to subside. In fact, this patient with only one kidney 
had, on the whole, less severe albuminuria and less toxic dis- 
turbance than many albuminuric primigravidse both of whose 
kidneys are known to be organically sound, though it is possible, 
and indeed probable, that in my patient's case the amount and 

1 In one case recorded in the discussion on Mr Twynam's paper on 
nephrectomy in pregnancy {Lancet, vol. i., 1898, p. 165), it is stated that 
after removal of one kidney in a man, for laceration, where all the work 
was thrown suddenly on the opposite organ, the amount of urine and 
urea became normal in four days' time. 



virulence of the toxin or toxins she was manufacturing were 
comparatively insignificant. It is manifestly impossible to 
institute comparisons between different patients on this point. 

The only other instance of which I have personally known 
where pregnancy occurred in a patient with one kidney, was in 
the case of a lady who was married about two years ago, after 
having had nephrectomy performed. Pregnancy shortly super- 
vened, and she died, I understand, of eclampsia shortly after a 
premature labour. 

One would, on the whole, I think, prefer, so far as one's 
limited knowledge goes, that patients who only possess one 
kidney, even though it is apparently a healthy one, should, if 
they marry at all, delay marriage till after the menopause. 
One could not, however, give such uncompromising advice ; it 
would be impracticable, and indeed in many cases hardly 
justifiable, besides being highly unwelcome to many of the 
recipients. Each case would require to be judged on its own 
merits, and after a careful consideration of all the attendant 
circumstances. Some patients might be determined to take a 
certain extra risk for reasons all-important to themselves, and 
such are apt to listen to no arguments which in any way run 
counter to their own views and inclinations. I should be 
strongly inclined to urge, in the interests of prudence, that 
marriage be delayed till at least three years from the operation 
of nephrectomy, so as to give the remaining healthy kidney 
ample time for compensatory changes to occur under the 
influences of the varying vicissitudes of ordinary life — in fact 
to establish and consolidate a condition of matters which will 
enable the one kidney safely and easily to do the work usually 
undertaken by two. 

Of course if the remaining kidney were diseased, marriage, 
where there is any possibility of child-bearing, should, in my 
opinion, be out of the question. 

Whenever a first pregnancy occurs in a patient with only 


one kidney, she should be most carefully watched, and placed 
in circumstances where this watching can be thoroughly and 
systematically carried out, her urine being examined and tested 
regularly during the whole duration of pregnancy, with the 
view of immediately bringing the pregnancy to an end should 
she show any evidences of renal inadequacy which fail to 
respond to general treatment. 

Special care should be taken to ensure that the excretion of 
urea is not diminished, and in this connection it is well to 
remember that the excretion of urea in healthy pregnant 
women seems to be considerably less than is usually supposed, 
varying, according to Whitridge Williams, from 20 to 24 
grammes in the twenty-four hours. I have certainly in some 
cases verified this observation, but was inclined to put it down 
to commencing failure of excretion, and diminishing power in 
the kidney function, in fact to commencing toxaemia. Be this 
as it may, there can be no doubt, as Marx has shown, that urea 
is always diminished in the toxaemia of pregnancy, and that 
this diminution is a much more valuable, and certainly an 
earlier indication, than either the presence of albumen or casts, 
both of which latter may be absent even in bad cases. If this 
were more generally recognised and acted on, there would, I 
feel sure, be fewer cases of eclampsia than we now have to 

The same general principles would hold, as regards sub- 
sequent pregnancies, in the case of a parous woman who had 
been the subject of nephrectomy, always bearing in mind the 
fact that primigravidae are more specially liable to the toxaemic 
disturbances which may be associated with pregnancy. 

The same remarks might be applied in the case of a woman 
with one kidney f unctionless, as, for example, in hydronephrosis, 
or where only one kidney is diseased and the other healthy, as 
proved by Luy's separator or by catheterising the ureters. In 
such cases of kidney disease it would be of great importance to 


discover the exact condition of each kidney, for in my opinion 
the prognosis as regards the supervention of pregnancy would 
be worse with two kidneys even slightly diseased, than where 
only one kidney is diseased (even considerably so) and the 
other healthy. The advantage one has in the case of the woman 
with only one kidney is that one knows exactly where one is as 
regards the condition of the remaining kidney, and can speak 
therefore with a more certain voice as regards probabilities and 

I have been unable to find much information in literature 
on this subject. There is a considerable number of cases 
recorded where, on account of urgent kidney complications, 
nephrectomy had to be performed during the actual existence 
of pregnancy, in many cases with satisfactory results both as 
regards the mother, the continuance of the pregnancy, and the 
health of the child. 

Fritsch says that pregnancy can be carried through with 
nephrectomy of one side, and quotes a case of Bovee's in 
support of this. He says, however, that the remaining kidney, 
if it becomes in a higher degree a "pregnancy kidney," may 
easily become insufficient, and that this may lead at once to 
the most serious eclampsia. Schramm, quoted by Cumston, 
records a case where the right kidney had been removed and 
pregnancy and labour were practically normal. He sums up 
by saying that a patient having but one kidney may go through 
pregnancy and labour without any injury to her health, but it 
is probable that such a patient would have diminished resisting 
power should she be afflicted with chronic nephritis, and that 
an attack of eclampsia would be fatal to her. In other words, 
with good fortune, she may pass through her pregnancy and 
labour safely, but any breakdown will necessarily tend to be 
greater, and therefore apt to be more disastrous. 

The variety of the complications which had to be dealt with 
in the following case was greater than I have ever before met 


with in any one patient, and the cases must be few in which so 
many obstetrical difficulties have been concentrated in one 
individual. For in addition to the fact that she had, some 
years previously, undergone the operation of nephrectomy, the 
patient was the subject of albuminuria, and had besides a 
contracted pelvis, placenta prsevia, and a cervical polypus, 
whilst, in the way of obstetric operations, induction of labour 
and craniotomy were required, and manual removal of an 
adherent placenta was necessary, in order to complete the third 

The notes of the case are as follows : — 

F. K, aet. 36, a primigravida, was admitted to the Edinburgh 
Maternity Hospital at 9.30 p.m., on the 29th December of 1905. 

The patient had last menstruated on the 20th of March 
1905, and on admission it was noted that in spite of the fact of 
her being a primigravida, and in the last month of gestation, 
the foetal head was not engaged in the pelvis, but was freely 
movable above the pelvic brim. The foetus lay in the left 
occipito-anterior position. 

The patient stated that she was quite well during her 
pregnancy till the end of October 1905, when her legs became 
so much swollen that she had to go to bed, where she remained 
for a week. She had been liable to occasional severe head- 

On 28th December, the day before her admission to hospital, 
she was suddenly seized with severe headache, and flashes of 
light before her eyes, but she noticed no swelling of hands or 
face. On admission, her urine, which was scanty, contained 2 
grains of albumen and 4 grains of urea per fluid ounce. She 
was thin and very pale, and there was considerable dropsy of 
the lower limbs, of the abdominal wall, and of the vulva. 

When five years of age she had had scarlet fever, followed 
by nephritis. In February 1896, her left kidney was removed 
for tuberculous disease. The symptoms which led up to the 


nephrectomy and which had lasted for twelve months before 
the operation, were progressive emaciation, blood in the urine, 
frequency of micturition, night-sweats, and attacks of severe 
pain in the left lumbar region. She states that she recovered 
well from the operation, but that the wound did not heal for 
twelve months afterwards. Since then she has remained well. 
She has now no pain or discomfort on micturition, but passes 
water rather frequently — every two hours or so. 

Menstruation began when she was 16. years of age, and 
recurs at intervals of twenty-four days. It is fairly profuse. 
She has no dysmenorrhoea or intermenstrual discharge. 

Examination of the pelvis showed an intercristal diameter 
of 10 \ inches, and an interspinous diameter of 8f inches. The 
diagonal conjugate was fairly normal, just slightly under 4J 
inches. The pelvis was, however, much contracted transversely, 
and was of a kyphotic type. 

The patient's general condition improved under milk diet 
and complete rest in bed. Her urine increased in quantity 
up to 50 to 60 fluid ounces per diem. The urea varied from 
2 J to 4 grains per fluid ounce, and the albumen decreased 
to 0*4 grains per fluid, ounce. 

In view mainly of the head not having entered the pelvis, 
it was decided to induce labour, as there seemed some hope 
of getting the head through if it were not too firmly ossified. 
Accordingly a bougie was introduced into the uterus on the 
evening of 3rd January 1906. There was some bleeding 
per vaginam after this, and this was at the time attributed 
to a small polypus which projected inwards from the left side 
of the cervical canal. There were occasional transient pains 
during the next twelve hours, and at the same time some 
further bleeding, not severe, but more than seemed to be 
accounted for by the cervical polypus. On careful examina- 
tion after the os became patent, there was found to be a 
lateral placenta praevia, with apparently a somewhat shrivelled 


placental lobe. The pains almost disappeared during the next 
twenty-four hours (even though the membranes had ruptured 
prematurely), and there was not much haemorrhage. On the 
morning of 5th January 1906, a Champetier de Eibes's 
bag was inserted through the os, which was about the size 
of a florin and very rigid. Strong pains came on during the 
day, and at 3 P.M. the patient was looking and feeling very 
much worn out, her pulse being 118 to the minute. At 
3.30 p.m. she was anaesthetised, the Champetier's bag was pulled 
slowly down, so as to fully dilate the cervix, as well as to 
stretch the vagina and perinaeum, the forceps was applied 
to the foetal head, and every effort was made to effect delivery 
in this way. All such attempts, however, proved futile, 
as the head was too large and too firmly ossified to pass through 
the pelvic brim. I therefore performed craniotomy, and the 
child was even then with difficulty extracted, as both the 
cavity and outlet of the pelvis were likewise transversely 
contracted. The child was delivered at 4.25 p.m., it was a 
male, weighing 5 lbs. 13 oz., and was 22 inches in length. 

The placenta was retained, and after half an hour I inserted 
my hand into the uterus, found it completely adherent, and 
verified the diagnosis of partial placenta praevia. After 
manually detaching and removing the placenta, an intra- 
uterine douche was given, and it was found necessary to insert 
three stitches into the perineum The placenta showed a 
shrivelled lobe. 

The puerperium was uneventful. The albumen steadily 
diminished and ultimately entirely disappeared, and the 
patient was discharged well on the twelfth day. 

This case is mainly of interest from the fact of the patient 
having only one kidney with which to face the strain of her 
first pregnancy and labour. Clearly, labour should have 
been induced at a much earlier date in order to have been 
of any service in giving the child a chance of life, but unfortu- 


nately the patient did not come under observation until too 
late for this operation to have been of any real advantage 
in the child's interests, and it was done therefore more for the 
mother's sake than from any great hope of saving the child. 

It is to be noted that the patient had a history of nephritis 
after scarlet fever in childhood, from which she seems com- 
pletely to have recovered, at least in so far as the right kidney 
was concerned. Her left kidney was removed for tuberculous 
disease in 1896, nearly ten years before her confinement, so 
that during all these years she had manifestly been entirely 
dependent on the right kidney for all her renal functions. 
Fortunately this kidney proved to be healthy, and rose to 
the occasion most satisfactorily. But if it was equal to the 
work required of it in the non-gravid state, the strain implied 
by the occurrence of pregnancy and labour, and the increased 
functional activity necessarily produced thereby, set up a 
condition of relative insufficiency, which fortunately, however, 
did not go the length of a complete breakdown. Had the 
pregnancy chanced to have been multiple, or had the toxaemia 
been greater, one could hardly have hoped for a favourable 


In the Handbuch der Geburtshiilfe, by von Winckel (Wiesbaden, 
1904), Zweiter Band, ii. Teil, page 1432, practically all 
the references to kidney operations during pregnancy 
are given. The reference to Twynam's case is given 
erroneously under " Frymann." 

Also, "Pregnancy and Labour following Nephrectomy," by 
Baldwin, Cleveland Medical Journal, 1903, ii., p. 213. 

Dr Brewis said he had listened with pleasure to the most 
interesting paper from Dr Haig Ferguson, and thanked him for 
bringing the case before the Society. Dr Ferguson had referred 



to the scarcity of instances of pregnancy occurring in the case 
of a patient with only one kidney. He had looked over his 
records and found that in April 1896 he had removed the right 
kidney from a Mrs B., and that in August 1898 Mrs B. had a 
child. He was told that there was no complication at all in the 
labour, and that the patient was still quite well. 

Dr James Ritchie said they had listened to a very interest- 
ing paper. When asked to attend a lady, he advised her to 
inform him should increased frequency of micturition occur, 
or if there was too small a quantity of urine, or if there 
was any swelling of the limbs. If the patient was otherwise 
healthy, he did not make further examination. If the patient 
were known to have an abnormal condition of the urine, it 
was one's duty to have the urine frequently examined during 
the whole time of pregnancy; if the patient be known to have 
only one kidney, one should make perfectly sure that that 
kidney was acting well by examining as to quantity of urine 
passed, its specific gravity, and the amount of urea. 

Dr Fred. Porter asked Dr Haig Ferguson why in the 
management of the case of labour, having diagnosed a contracted 
pelvis and partial placenta praevia, turning had not been 
attempted With regard to albuminuria and one kidney only, 
and Dr Ferguson's advice for the woman not to marry till the 
menopause, he considered the advice rather hard, and until one 
knew what albuminuria and eclampsia were really due to, he 
would not advise non -marriage. He had had an experience of a 
lady who had become pregnant after nephrectomy, and though 
the case had not been under his care, he knew that she had a 
child two years after the nephrectomy, and that it was an 
absolutely simple labour, and the child was still living 

Dr Haig Ferguson, in reply, said that he did not say he 
advised a woman not to marry under such circumstances. As 
to the treatment carried out, the placenta prsevia was not 
diagnosed till the membranes had ruptured, and it was a \ery 


partial placenta prsevia; the lobe presenting was somewhat con- 
tracted. Further, one could not have turned well in a kyphotic 
pelvis with a narrow outlet. Even if the condition had been 
recognised earlier, he did not know that he would have con- 
sidered version as at all a practical procedure in the circum- 


By Dr Garnet Leary (Communicated by the Secretary). 

In this communication the author gives his experience of anti- 
streptococcic serum in the treatment of cases of puerperal sepsis 
occurring during 1900-1902 in an extensive club and mixed-class 
practice Eecovery took place in all the cases, this successful 
result being ascribed to the combined and persistent use of in- 
tra-uterine douches along with the administration of the serum. 

At the onset of symptoms of infection intra-uterine douches 
of corrosive (1 in 1000) or creoline (51 to pint) were generally 
given twice or three times daily, carbolic (1 in 40) being 
substituted after a few days. In cases where, after the lapse 
of two or three days, no improvement took place in pulse and 
temperature, and whenever the temperature rose to 103° F. to 
104° F., and pulse to 120, curettage by a blunt instrument was 
performed, and fresh antistreptococcic serum employed and 
repeated frequently, according to the severity of the symptoms. 

Opportunities for making microscopical examination or 
taking cultures were not available; but the occurrence of 
rigors, high fever, rapid pulse, sweats, diarrhoea, and marked 
wasting distinguished most of the cases as of true streptococcic 
origin. In a smaller number of cases the symptoms, while 
alarming, were less severe, and yielded to intra-uterine douching. 
In these the infection was probably saprophytic. 


The following cases are detailed, viz. : — 

Case I. — Multipara, set. 32, with previous history of heart- 
disease, was seized with haemorrhage at sixth month of preg- 
nancy, and when seen some hours later was collapsed, with 
almost imperceptible pulse. The os was dilated to the size 
of -a florin. Pains being weak and hemorrhage continuing, a 
diagnosis of accidental haemorrhage was made, dilatation com- 
pleted by the fingers, and a six months' foetus was delivered by 
forceps. The placenta was stripped from the uterine wall, the 
uterus irrigated with creoline and corrosive, and the patient 
freely stimulated. As collapse continued, saline injections were 
given, foot of bed raised, legs bandaged, etc. After remaining 
semi- comatose for twenty hours, she rallied slowly to the fourth 
day, temperature keeping 99° F. to 100° F. On the fourth day 
the temperature rose with a rigor to 105° F., pulse 168 and 
thready, and she appeared to be sinking. Cold sponging and 
administration of quinine and phenacetin causing only slight 
temporary improvement, 10 c.c. antistreptococcic serum were 
injected into the abdominal muscles. This was followed at first 
by another rigor and rise of temperature, but in six to ten hours 
temperature fell to 102° F., and pulse was stronger and 152. 
Another injection was given and followed by another rise in 
temperature to 104° F., and a third injection twelve hours later. 

Next day temperature was 100° F., pulse 140, and patient 
showed much general improvement, becoming for the first time 
able to mutter a few words and to recognise those around her. 

Improvement was gradual and steady from this point, and 
patient was able to leave her bedroom in two months. After 
a few months further treatment for her heart lesion, she was 
in better health than she had been for years. 

Case II. — Multipara, set. 28, was seized with profuse 
haemorrhage at the eighth month. The os was dilated to the 
size of a crown piece, but pains were few and feeble, and as 


haemorrhage continued profuse and edge of placenta could be 
felt presenting, the membranes were artificially ruptured, 
turning effected, and the uterus plugged by traction on the 
foetal legs. After saline injections and stimulants had been 
given to combat the profound collapse, delivery of a dead foetus 
was accomplished. The placenta, which was adherent, was 
then removed piecemeal with difficulty, and the uterus curetted 
and douched. Collapse was again profound, but patient rallied 
in a few hours, and made satisfactory progress until the third 
day, when septic symptoms supervened, with rapid pulse, pain, 
and distension of abdomen, accompanied by offensive discharge. 
These symptoms continued, in spite of douching twice daily, 
until the sixth day, when temperature, which had been 101° F. 
to 103° F., rose with rigor to 105° F., pulse 140. Intra-uterine 
douching was continued, cold sponging done, and quinine 
sulphate, phenacetin, and sodium salicylate given internally, 
with improvement for some hours, but as temperature again 
rose to 104° F., 10 c.c. of serum was injected. Ten hours later 
temperature fell to 100-5° F., pulse 120; patient began to take 
food, and looked better. Serum was repeated next morning. 
For two days temperature remained between 100° F. and 102-5° 
F., pulse 100 to 120, intra-uterine douching being continued. 
A third injection was then given. The symptoms became 
greatly improved, but further complications supervened in the 
form of pelvic peritonitis with abscess in the pouch of Douglas 
and a mammary abscess. The administration of the serum 
on several occasions at this stage seemed to give beneficial 
results, the abscesses being also incised and drained. A 
threatening abscess, in the other breast seemed to be aborted 
by a timely injection. Kecovery was then rapid, and patient 
left her bed some three weeks later, but a few days afterwards 
developed phlegmasia alba dolens, from which she made a good 
recovery after six weeks treatment: was able to resume her 
work in a factory, and enjoyed good subsequent health. 


Case III. — Mrs C, primipara, was delivered by forceps of 
a large full-time child with difficulty because of hip-disease 
and slight pelvic deformity. The perineum was torn badly, and 
stitched, but did not heal well. On third day lochia were 
offensive ; temperature 99 '5° F., pulse 104. Intra -uterine douches 
were given twice daily, stitches removed, and edges of wound 
purified. At the end of a week, during which temperature kept 
from 100° F. to 102° F. and pulse 100 to 130, patient had a rigor, 
and gave much trouble with noisy delirium. During the next 
few days serum was injected four or five times, each dose being 
followed in five or six hours by marked improvement. The 
temperature came down to 99° F., pulse 108, and she became 
quiet and rational, and took more nourishment. Improvement 
was steady for three weeks, when, after being up, abscesses 
developed in both mammae, and slight phlegmasia alba dolens 
came on in left leg. Serum was used for both conditions, and 
appeared to markedly ameliorate the symptoms. In six weeks 
she was quite well, and able for her household duties. It was 
subsequently ascertained that the midwife in attendance on 
this patient had come to her from attendance on a fatal case of 
puerperal septicaemia. 

Case IV. — Mrs O., multipara, was delivered by forceps for 
tedious labour, a small perineal tear being stitched. The 
perineum suppurated, and on fourth day temperature rose to 
100° F., pulse 108, and an offensive discharge was present. In 
spite of douching, temperature and pulse continued to rise, and 
on sixth day curettage was done. This was followed on eighth 
day by a rigor, and patient became semi-comatose for several 
hours. A serum injection reduced temperature to 101° F., 
pulse 115. Next day another rigor occurred, with collapse and 
unconsciousness for nearly twelve hours. Patient was freely 
stimulated, and two more injections of serum were given. Next 
day temperature was 100° F., pulse 110, and general condition 



quiet and reasoning. She continued to make a remarkable 
recovery, and was able to get about at the end of the third 

As Cases II., III., and IV. occurred in succession, at a 
few weeks interval, the author suggests that the midwifery bag 
may have been instrumental in transmitting the infection, 
which view was strengthened by the cessation of the series 
after thorough sterlisation of the bag and its contents. 

Case V. occurred in the practice of Dr T. Leary, J.P., father 
of the author, in 1902. Mrs S., set. 20, was delivered by 
forceps, the perineum being slightly torn, but not requiring 
stitching. The patient progressed normally until the fourth 
day, when temperature rose to 101° F., pulse 110. Next day a 
slight rigor occurred, accompanied by vertigo, restlessness, and 
some delirium. There was tenderness in the left iliac region, 
and diminished lochia and milk secretion. Douching twice 
daily with corrosive sublimate was carried out up to seventh 
day, when temperature, which had hitherto kept about 101° F. 
to 102-5° F., rose to 104° F., with marked exaggeration of the 
previous symptoms. The pain over the uterus was so severe 
as to necessitate morphia suppositories. Pulse was 140, of good 
volume, and regular. At night patient became prostrate and 
semi-comatose, and showed tremors and twitchings. As patient 
seemed worse next morning, antistreptococcic serum was tried, 
on the suggestion of the author. The improvement by the 
following morning was remarkable, and temperature had fallen 
to 100° F., pulse 116. The same evening another injection was 
given, with equally satisfactory result, the temperature falling 
the following day to 99 - 5° F., and the diarrhoea, which had been 
intractable for days, ceased. Four days later a relapse, with rise 
of temperature to 102° F., pulse 100, and recurrence of pain, 
flushing, and diarrhoea, yielded promptly to other two serum 


injections. Progress after that was uninterrupted, and patient 
was able to resume her household duties ten days later. On 
searching for the cause in this case, the fact was elicited that a 
lodger in an adjoining room was suffering from erysipelas. In 
this case, which was therefore in all probability a pure strepto- 
coccus infection, the serum seemed to have a more directly 
beneficial effect than in the other cases. This result may also 
have been due to the more frequent repetition of the dose, as 
three serum injections were given within twenty-four hours 
and two the following day. 

General Remarks and Conclusions. — In none of the cases did 
metastatic abscesses occur as the result of the use of the serum, 
nor was any local suppuration met with. The serum used was 
always fresh, and both Burroughs Wellcome's and Parke Davis's 
preparations were used. 

After referring to the diversity of organisms that may give 
rise to septic conditions after labour, including different varieties 
of the streptococcus, Loeffler's bacillus, and bacillus coli, either 
in pure or mixed infections, as accounting in some degree for 
the apparently contradictory clinical results in cases where 
serum has been employed, Dr Leary summarises his conclusions 
as follows : — 

1. The serum should be used in all cases which do not give 
way rapidly under treatment by douching, drugs, etc. 

2. A bacteriological examination should, if possible, be made 
from the cervical and vaginal discharge. 

3. Frequent repetitions of the serum should be given, de- 
pending on the severity of the case, especially noting the pulse. 

4. Treatment of all complications that may arise should 
include use of the serum. 

Dr Keppie Paterson said it was a very interesting paper to 
which they had listened. He said he had himself used serum 


in two of his cases without any evident benefit — in one case 
several injections had been given. He felt that the injection of 
serum in test cases of fever in the puerperium was very much 
empirical until one could make sure what germ they had to 
deal with. In one of his cases he had obtained a blood culture, 
and bacillus subtilis was the germ found. It was really 
necessary to obtain a culture from the secretion within the 
uterus and from the blood in these cases. Then one might 
hope to benefit the patients by the use of the particular serum. 

Dr Lamond Lackie considered that an intra-uterine douche of 
1 in 1000 corrosive was too strong to be used. The curettage also 
was not a very satisfactory treatment, for there was great risk of 
opening up new channels of infection. As to his present experi- 
ence of the use of antistreptococcic serum, it had been eminently 
unsatisfactory. Any success that had been obtained in any 
case, he thought, might quite well have been due to the local 
treatment — the careful washing out of the uterus with saline 
or sterilised water. The difficulty was to know exactly what 
the sepsis was due to. To overcome this difficulty, a polyvalent 
serum had to be introduced, made from various species of 
streptococcus, and that form of serum was supposed to be more 
able to counteract the poison. But it seemed to him that one 
would need to use an enormous dose of the serum in order to 
give the antidote of the particular streptococcus present. In 
sapremia the serum was practically useless, but with local 
treatment one obtained satisfactory results. In real cases of 
septicaemia one would like to have a serum, but serum had had 
no effect in his experience. A Committee in New York had 
come to the conclusion that the serum was absolutely worthless 
in these cases. In cases in which good appeared to have been 
obtained, it seemed difficult to know exactly what had done 
good. A temperature might be 101° F. in the afternoon, and 
next day it might be normal, the fall being due to natural 
causes, the blood alone having overcome the poison. 


Dr Haig Ferguson quite agreed with Dr Lackie as to the 
failure of the serum to do any good even in cases where blood- 
cultures and the secretion in the uterus had been examined 
and the streptococcus found. In these cases one would have 
expected, a priori, some advantage to have arisen from the 
exhibition of the serum. Personally, however, he had seen 
either no benefit, or very little, from its use. As to scraping the 
uterus, it was a dangerous thing to do — opening up fresh sur- 
faces. As to the use of 1 in 1000 corrosive in an intra-uterine 
douche, he thought it to be very dangerous to use in a puerperal 
uterus. Nothing stronger than 1 in 4000 should be employed. 

Meeting III. — January 9, 1907. 
Dr J. W. Ballantyne, President, in the Chair. 

I. The following gentleman was elected an Ordinary Fellow 
of the Society:— A. M. Crennan, M.B., Ch.B., 36 Woodburn 
Terrace, Edinburgh. 

Dr Haidtain showed — (a) TWISTED PAROVARIAN CYST with 
an intraligamentary haemorrhage — the ovary not being at all 
involved, (b) A specimen of diffuse uterine fibrosis, in 
which, as usual, the mucous membrane was much hypertrophied. 
(c) A sarcomatous uterus, round celled, which filled up the 
entire cavity, perforated the wall, and involved the peritoneal 
cavity. The operation had been performed seven or eight 
months ago, and at present the patient was quite well, (d) Uterus 
removed for perforating abscess of its wall. The case was one 
of septicaemia after abortion. On opening the abdomen it was 
found filled with purulent material, and the uterus was found 
perforated. It seemed a desperate case ; the temperature was 
about 104° F. at the time of operation, but the patient is absolutely 


so far recovered, (e) Three specimens of mucous polypus and 
adenomatous growth, associated with fibroid uterus. In one 
of the specimens the mucous polypus is growing on the base of 
a fibroid. (/) A multiple fibroid of uterus, giving rise to 
retention of urine. The special interest of the specimen was, 
that on the right side the tube seemed as if it had passed down 
into a sulcus, which seemed to be formed by a fibroid in the 
round ligament, which had turned over. But the condition was 
a very difficult one to understand. 


By Dr Frederick Porter. 

The President and Fellows, — I thought this case of suf- 
ficient interest to place before this Society. So far, I have 
failed to find any record of a case presenting a similar train of 
symptoms, but there is possibly some Fellow present who has 
had experience of a similar case. 

Mrs M'L., age 34, multipara, has had three children, youngest 
four years of age. All her labours were natural and easy. I 
saw this patient first on 19th April 1905, when she complained of 
general weakness, pain in the back, pain in the right hypochon- 
driac and lumbar regions, especially when she walked. These 
symptoms were relieved by lying down, except the pain in the 
back, which was more severe. She informed me that she suf- 
fered from the above symptoms for the past five years, and con- 
sulted me as she was feeling more run down than usual. For 
the last six or eight months her menstruation was regular every 
twenty-one days, but very scanty, the period lasting one day. 
There was slight dysmenorrhea. She suffered considerably 


from flatulence, and had every appearance of a chronic dyspeptic. 
Heart and lungs were apparently sound. There were no hsemic 
bruits ; pulse 74 per minute ; soft tension. 

Abdominal Examination revealed on palpation a freely 
movable tumour, which was easily palpable on deep inspiration, 
and with slight pressure disappeared from the hand and seemed 
to dip down under the liver. In size and shape it seemed to me 
to have the characteristics of a large kidney, and I diagnosed 
the case as a movable hydronephritic kidney. Eectovaginal 
examination revealed no abnormality. Urine was acid, slight 
mucus-like deposit, no albumen, sugar, or blood. Deposit on 
microscopical examination revealed a number of large squamous 
and pyriform cells, and a few leucocytes. I ordered the patient 
a kidney belt, which relieved the back weakness, but with no 
other appreciable results. 

I examined the urine at intervals of a month, and found it 
always practically similar to my first examination. One 
specimen exhibited a larger number of squamous and pyriform 
cells and leucocytes than any previous specimen. 

I may here state that I examined this patient's urine so 
frequently, as I was anxious to discover the significance of the 
presence of these cells, as I had previously observed that in 
several urines, and as I thought I was dealing with a pure 
kidney condition, I might find out their exact nature. I will 
refer to this later. 

History of Present Illness. — On 3rd November 1905, patient 
complained of severe headache. 

4th November. — Headache had disappeared, and she felt in 
her usual health. 

5th November. — She complained of breathlessness, with a 
choking sensation, and felt sick. She lay down in bed for an 
hour, but as this increased the above symptoms, she rose and 
sat up till her usual bed-time. She slept all night. 

6th November. — Complained of breathlessness, but rose and 


did her house duties. She noticed, when dressing, there was 
considerable swelling of the lower limbs. 

7th November. — Her husband noticed there was swelling of 
the face and abdomen. On examining the legs at night he saw 
they were swollen as far as the ankle. She complained of sick- 
ness throughout the day. 

8th November. — On dressing in the morning, she found she 
could not get her corsets to meet, on account of the general 
swelling. Her arms and hands were greatly swollen. Other 
symptoms similar to the previous day, except that she vomited 
twice. I was asked to see her in the evening, and found a 
general oedema of the whole body. Face, arms, hands, chest, 
legs, and feet, all pitted freely on pressure. She was very 
breathless, and complained of pain in the right iliac region, and 
said she had passed a small teacupful of urine in the twenty-four 
hours. Pain in the back was still present, but she was quite 
free from pain in the right hypochondriac region (the previous 
seat of pain). She had very severe headache. Pulse was 
regular (72 per minute), tension high. 

Heart on Palpation. — Apex beat was strong and heaving, 
and was shifted about \ inch to the left. 

Auscultation. — Sounds were clear, second accentuated and 
metallic ; there were no murmurs. 

Abdomen was distended and (edematous. I could not 
detect the movable tumour in the right hypochondriac region ; 
over the right iliac there was resistance on palpation, and on 
deep palpation she complained of pain. Percussion note in 
this region was duller than the opposite side, and remained so 
after patient was put in the lateral position. 

Urine was alkaline, sp. gr. 1022. After adding acetic acid 
and boiling, it gave a copious deposit of albumen which was 
almost solid. There was also a little blood present. 

Microscopically. — Eed and white blood-cells, a large amount 
of epithelial cells, and a few hyaline casts. 


As I assumed my previous diagnosis was correct, I came 
to the conclusion that the kidney was displaced into the pouch 
of Douglas, and the ureter had become twisted in the process, 
thus causing the nephritic symptoms. 

Patient was given a saline aperient and a mixture of potass 
acetate, hyoscyamus, buchu, etc., and put on a milk diet. 

9th November. — Headache had disappeared ; patient passed 
a normal amount of urine, which contained less albumen ; there 
was no blood, but casts still present. Dr Haultain examined 
the patient in the evening, and practically corroborated the 
diagnosis. On vaginal examination he found a body lying in 
the pouch of Douglas, which he thought might be the edge of a 

10th November. — Patient felt better ; headache still absent, 
and she was less cedematous ; face was still puffy, but there was 
no oedema of legs and arms. In the evening she was removed 
to the Deaconess Hospital, with a view to operation. 

She remained in bed till 15th November, where she felt 
quite comfortable. Urine still contained a considerable amount 
of albumen, and casts were still present. Mr Alexis Thomson 
operated, and removed a multilocular pedunculated cyst, which 
was attached to the broad ligament, and which he found pressing 
on both ureters. 

Patient remained in hospital a fortnight, and though the 
operation was entirely successful, the nephritic symptoms did 
not improve, but steadily got worse. I believe, while in hospital 
the amount of albumen was estimated for the first day or two 
after the operation, but when the albumen was found to be 
increasing, an estimate was no longer taken. I regret that I 
have no accurate notes of the daily output of albumen. 

When patient returned home, 1 put her on a milk diet, gave 
diuretic mixture she had previously, and kept her in bed. 
The albumen steadily decreased in amount, and on 22nd January 
(nine weeks after operation) there was no trace. On question- 


ing her about the diet she got in hospital, she informed me 
that two days after the operation she had been on an ordinary 
convalescent diet — chicken, rabbit, milk pudding, apple tart, 
etc., and this no doubt accounted for the increased albuminuria. 

Her after-history was without interest, except that I found 
a difficulty in getting her to take nitrogenous food without 
causing a return of the albuminuria. After the urine was free 
from albumen, I waited a week and supplemented the milk 
diet with different preparations of plasmon, biscuits and powder, 
which I ordered in milk puddings, and plasmon cocoa (this was 
experimental). I found on this diet there was a return of 
albuminuria. I changed the diet, and gave her oatmeal porridge, 
green vegetables, tomatoes, milk puddings, and milk ad lib. 
After a fortnight there was no return of albuminuria, and I 
gradually introduced chicken soup, veal, tea, etc. 

I examined her urine, at first fortnightly and then monthly, 
but found no trace of albuminuria. She is now on an ordinary 
light mixed diet, and she is in every way better. She suffers no 
pain anywhere, and at present is four months pregnant. Her 
urine is free from albumen, but there is still a number of 
squamous and pyriform cells present. 

This case, I think, may strike you as presenting some analogy 
to the albuminuria of pregnancy. When I was asked to see 
this patient on 8th November 1905, I had examined her urine 
ten days previously, and then found no trace of albumen. 
Thus there is no doubt the albuminuria was of sudden onset. 
It is significant also that the movable tumour which was 
situated in the right hypochondrium was no longer in that 
position, and finding a dull resistant area in the right iliac 
region (which previously did not exist), I feel I was justified 
in the inference that the tumour was displaced into the pelvis, 
and was at least a factor in causing the nephritis. 

As the operation showed, my diagnosis was incorrect. Had 
it been a displaced kidney with a twisted ureter, then I think 


the symptoms this patient suffered from might all have been 
attributed to this, with some possible weakness in the other 
kidney. As the case now stands — " a tumour attached to the 
broad ligament and pressing on both ureters" (these are the 
surgeon's words for what he found) — I feel that I cannot 
logically conclude that this could be sufficient to cause such 
severe symptoms in any person with healthy kidneys. The 
question, I feel, that naturally follows, is : Are this patient's 
kidneys healthy, or are they in a state of nephritis ? From text- 
book descriptions of symptoms of nephritis, I think I am justified 
in saying that this patient suffered prior to the displacement of 
the tumour, and does not at the present time suffer from nephritis. 
From observations I have made on urines of pregnant and other 
women, and with my present knowledge of those urines, I 
believe that this patient suffered from some catarrhal condition 
of one or both kidneys, and I arrive at this decision from the 
condition of her urine. 

I fear, Mr President, I can only give you a hypothetical 
reason for this belief. I have found in three cases I have met 
within the last eight months a similar condition of the urine to 
this patient. In two of those cases an albuminuria supervened, 
one at the sixth month and another at the eighth month of 
pregnancy. The other case escaped, and, I believe, on account of 
a very strict diet. All I can say about the urines of those 
cases is, that they all showed, microscopically, a number of large 
squamous and pyriform cells and leucocytes. These may be 
cells from the bladder, as authorities on the subject say that 
cells from the bladder and kidney are very difficult to dis- 
tinguish. My experience (which may be fallacious) has 
taught me that in bladder cases it is seldom those cells are met 
with so freely without the presence of pus, and whenever I find 
those cells persisting in a urine, I always examine the urine 
frequently, and place the patient on a strict diet, as I believe 
they are suggestive of a catarrhal condition of the kidneys. 


In conclusion, I think I might safely say that if this 
patient had not sought medical advice when she did, and I had 
not found what I supposed to be a movable kidney, this case 
might have been diagnosed as a case of uncomplicated nephritis. 
The lesson this case has taught me is to make an abdominal 
and pelvic examination in acute albuminuria in women. 

The President said that the Society had had an interesting 
case record put before it — one that presented just the amount 
of problematicalness that would lead to different opinions as to 
the possible causation. Most of the Fellows were familiar with 
tumours beginning in the pelvis and growing into the abdomen, 
and thus giving rise to a new group of clinical features, e.g., in 
fibrosis of the uterus. According to Dr Porter's explanation, 
the opposite was the case in this patient, although of course the 
cyst must have been down in the pelvis at the first, and had 
then grown up, and been displaced downwards again. The 
President cited a case where a tumour, thought to be a kidney, 
had been displaced downwards, and apparently had been the 
cause of a bad attack of haemorrhoids. Two years subsequently 
it had been found to be a gall-bladder full of gall-stones which 
was down in the pelvis. 

Dr Haultain said that from the history of the case, from 
the fact that the tumour had been felt in the right iliac region, 
and also from the fact of the albuminuria (which he had not 
seen before associated with tumours of ovary or uterus), he was 
led to believe that he had to deal with a kidney, and in 
accordance with his belief that gynaecologists should only take 
cases associated with pelvic organs, he had asked his colleague, 
Mr Alexis Thomson, to see the case and give his opinion upon 
it. Mr Thomson had been vague about the diagnosis, but had 
opened the abdomen, while he (Dr Haultain) had had the 
pleasure of assisting him, and had found an ovarian cyst. He 



thought it showed one the great importance of going very 
thoroughly into these cases, but that however thoroughly one 
did go into them, that sometimes one's diagnosis must be 
absolutely wrong. He had operated upon a considerable 
number of ovarian and fibroid tumours, and had never seen 
anything like the amount of albuminuria present in this case. 
What exactly had been the cause of it was difficult to say. 
There had been no great dilatation of the ureters, but it seemed 
as if there must have been some pressure on the ureter on one 
side, although it was not noticed at the time of operation. 
Abdominal section had been indicated, and the operation was 

Professor Kynoch said he had had pleasure in listening to 
the paper. He had been going to ask if there had been any 
dilatation of the ureter, or any kinking of it, but Dr Haultain 
had already said there was not any. 

Dr Ritchie said that Dr Porter had, before the operation, 
diagnosed a movable kidney. What was the condition of that 
kidney after the operation? One of the practical lessons of 
this case was that when albuminuria was present, it was of 
great importance that the patient be dieted very carefully till 
the albuminuria had completely disappeared. 

Dr Porter, in reply, thanked the Fellows for their kind 
reception of the communication. As to Dr Kitchie's question, 
the patient had a general slight enteroptosis, both kidneys 
were slightly movable, and the liver slightly displaced. As to 
the suggestion that the albuminuria was something apart from 
the tumour: it might have been so, but he had examined 
frequently before, and knew the position of the tumour, then, 
called in suddenly and finding no tumour, but a dullness in the 
right iliac region, he was justified in taking up the explanation 
he had given. 



By Elizabeth H. B. Macdonald, M.A., M.D., Ch.B., Carnegie Research 
Scholar, University College, Dundee. 

Many cases of severe uterine haemorrhage, occurring near the 
menopause and without obvious cause, have been reported within 
recent years. The pathological findings in. these cases have 
been almost as various as the constructions put on the patho- 
logical conditions in the attempt to explain the haemorrhage. 

Nearly all have shown thickened blood-vessels, and the 
vessel changes have been regarded by many observers as the 
causal factor. In particular, Eeinecke, in 1896, reported four 
cases where hysterectomy was performed for bleeding, and 
where the pathological examination showed the most marked 
changes to be in the vessels. He explained the hsemorrhage as 
due to the inability of the thickened, rigid vessels to respond 
to vasomotor stimulation. Cholmogoroff, Pichevin, and Petit, 
and more recently Barbour and others, have reported similar 
cases. But the connection between uterine arterio-sclerosis on 
the one hand, and uncontrollable uterine hsemorrhage on the 
other, has not been clearly established. Cases are known 
where a marked sclerotic condition of the vessels has been 
unattended by haemorrhage, and the occurrence of serious 
haemorrhage has been noted where the vessels showed no 
marked change. 

Pozzi, in 1899, still seeking the cause of haemorrhage in the 
condition of the vessels, differed from other observers in finding 
the thickening in and around the vessel walls due mainly to an 
increase in elastic, and only to a less extent in fibrous, tissue. 
The great increase in the elastic tissue of the organ gave to it, 
he considered, a peculiar resistance, and paralysed its contracting 
power, so that haemorrhage readily occurred. Anspach, on the 


other hand, in a recent paper (1906) demonstrates the physio- 
logical increase in elastic tissue in muciparous uteri, and 
suggests that the cases of bleeding, which, as being in his 
opinion dependent on a pathological condition of the muscula- 
ture, he designates "metrorrhagia myopathica/' may be due to 
a failure in the normal increase of elastic tissue. 

Theilhaber, noting the extreme difficulty of distinguishing 
physiological from pathological changes in the blood-vessels of 
an organ subject to such functional variations as the uterus, 
and believing that the majority, if not all, of the changes 
described as arterio-sclerosis are conditions normal in a parous 
uterus, lays stress on the part played by the musculature in 
the occurrence of haemorrhage. But exactly the same difficulty 
in distinguishing what is pathological from what is physiological 
arises here. What is the normal proportional increase of 
fibrous tissue to muscular tissue with advancing age and 
repeated pregnancies? When does Theilhaber's "muscular 
insufficiency " arise ? 

Other observers have sought the cause of the haemorrhages 
in ovarian changes. That all the causes have a very definite 
connection with the periodic ovarian stimulation on which 
menstruation depends, is quite clear from the histories. None 
of the patients manifesting uncontrollable haemorrhages of 
obscure origin was past the menopause ; and, as Barbour justly 
remarks, "Arterio-sclerosis after the menopause has been 
frequently described, but never as accompanied by serious 

A consideration of the mode of occurrence and control, so 
far as we know it, of the normal menstrual haemorrhage, may 
throw some light on the causation of abnormal uterine haemor- 
rhages. It is clear that the normal haemorrhage is brought 
about and controlled by several factors, and that a disturbance 
in any one of these may cause irregularities. 

That a gradually increasing pelvic congestion occurs and 


culminates in haemorrhage mostly by diapedesis, but partly also 
at the height of the congestion by rupture of some of the 
endometrial capillaries, has been sufficiently demonstrated ; as 
also the fact that this periodic congestion is dependent on the 
ovaries. Whether the general rise of blood pressure is due to 
an internal ovarian secretion exerting its influence through the 
blood, or is determined by nervous influences, or depends on 
both these factors, is still doubtful. But at least it is safe to 
assume that variations in the normal stimulation may result in 
abnormalities of menstruation. 

No less important than the ovarian stimulus is the response 
of the uterus, and here it will be convenient to consider 
separately the response of the musculature, including the blood- 
vessels, and of the endometrium. 

The part played by uterine contractions in controlling 
haemorrhage has been fully described by Theilhaber. He points 
out that during the greater portion of the menstrual period the 
uterus is large and flabby; then contractions occur which 
become gradually longer, while the bleeding becomes correspond- 
ingly less, until finally the flow ceases completely, strong and 
continued contraction being necessary for this complete cessation. 
Similarly, in the puerperium, the cessation of lochial discharge 
is dependent on contraction of the muscle. Thus, he argues, if 
the muscular contraction is insufficient, hyperaemia results, 
with its probable secondary results in swelling and oedema of 
the uterine parenchyma, and following these, long-continued 
monorrhagia may readily occur. Anspach explains the actual 
occurrence of menstrual haemorrhage as due to obstruction to 
the venous return, whereby congestion is produced, resulting 
naturally in diapedesis, the obstruction being caused by weak 
uterine contractions narrowing the veins, but failing to narrow 
in a corresponding degree the thicker-walled arteries. This is 
essentially the view of Theilhaber, leaving us to infer that the 
cessation of the haemorrhage will be brought about by con- 


tractions strong enough to close the arteries as well as the 

Any explanation of uterine haemorrhage that even only 
apparently separates, in regard to its action, the uterine muscle 
from the blood-vessels, appears to me to be defective. The 
uterus may be ideally considered as a muscular expansion of 
the vascular walls, as Keiffer, from his study of the histology 
of the nervous system in the uterus, points out. Vasomotor 
stimulation causes contraction or relaxation of the whole 
uterus. The involuntary muscle of the vessel walls is to be 
regarded as essentially part of the uterine musculature, subject 
for the most part to the same variations and the same patho- 
logical changes. From this point of view it appears possible 
that during the height of menstrual congestion the pressure 
within the vessels is such as to paralyse their contracting 
power, and that as the pressure lessens, partly from escape of 
the blood and partly probably from natural diminution of the 
ovarian stimulus, the vessels regain their tone, and the uterus 
responds to the vasomotor stimulation by contractions sufficient 
to stop the haemorrhage. For the complete cessation of the 
flow, strong and lasting contraction is necessary, but this is 
brought about as a response on the part of the entire muscula- 
ture to vasomotor stimulation. It follows that any cause 
interfering with the normal response of the musculature may 
cause irregularities of menstruation. 

The response of the endometrium to the menstrual stimulus 
is important and interesting. The gradually increasing con- 
gestion causes a definite swelling of the mucosa, so that the 
stroma cells become more distinct in outline and later polyhedral 
from mutual pressure, while the glands appear larger from 
swelling of their epithelial cells. The surface capillaries show 
a remarkable power of distension to accommodate the increased 
supply of blood, and appear also to increase in number, so that 
some observers have thought that new capillaries are formed. 


But it is possible that the delicate-walled collapsible tubes 
become apparent only when in a more or less distended con- 
dition. The actual haemorrhage occurs by diapedesis through 
these delicate capillary walls, and partly also, in all probability, 
by rupture of some of them, the corpuscles finally forcing their 
way between the individual cells of the surface epithelium, or, 
by dislodging one or two adjacent epithelial cells, finding a 
freer exit. 

What is true of normal haemorrhage is true also as regards 
the mode of occurrence of abnormal uterine haemorrhage. 
There is no suggestion in any of the recorded cases of severe 
bleeding that rupture of the presumably diseased vessels had. 
occurred. The haemorrhage occurs by capillary oozing, an over- 
distension of the endometrial capillaries being first produced ; 
and the ease with which haemorrhage occurs depends to a 
considerable extent on the healthy condition of the capillaries 
and their resisting power. One would expect, therefore, that 
any disturbances in the circulation, whether arising from 
increased arterial supply causing over-filling of the capillaries, 
or from venous obstruction producing over-distension by back- 
ward pressure, would tend to produce uterine haemorrhage. 
And there is little doubt that such circulatory disturbances 
would result in the appearance of haemorrhage much more 
commonly than they do, were it not for the peculiar character 
of the endometrium, its unique readiness of response to stimu- 

So far, therefore, the causes of abnormal uterine haemorrhage 
fall naturally into three groups : — 

1. Abnormalities in the periodic ovarian stimulation. 

2. Conditions giving rise to muscular insufficiency, either 


(a) actual deficiency of muscular tissue, or 

(b) loss of tone, and consequent deficient response to 

vasomotor stimulation . 


3. Conditions giving rise primarily to continued congestion 
of the endometrium, either from 

(a) increased arterial supply, or 

(b) venous obstruction. 

1. Of ovarian changes and their effect on menstruation, we 
know comparatively little. We know from actual experiment 
that the growth of the uterus depends directly on the healthy 
functional activity of the ovaries, that the complete removal of 
the latter results in atrophy of the uterus and of the genital 
organs generally, and that the retention of even a small piece 
of healthy ovarian tissue is sufficient to prevent these regressive 
changes. Physiologically, there is a gradual lessening of ovarian 
activity as the menopause is approached, and this is accom- 
panied by these general regressive changes, atrophy of the 
uterine muscle and mucosa, thickening of the walls of the 
vessels with narrowing of their lumina, and the gradual cessa- 
tion of menstruation. 

Menorrhagia in connection with ovarian disease, especially 
early cystic changes in the ovary, is well known to occur, and 
was noted many years ago by Lawson Tait. The haemorrhage 
in these cases is unaffected by curetting, or, indeed, by any 
treatment save removal of the diseased organ. The endome- 
trium often shows no appreciable change from the normal — a 
noteworthy point, in view of the manifold forms of change which 
it is liable to show in cases of venous congestion. Exactly how 
the monorrhagia is brought about is not clear. Brennecke's 
explanation of the cases which he named " endometritis hyper- 
plasia ovarialis " was based on Pfluger's theory that menstrua- 
tion is directly dependent on ovulation. But this theory has 
since been shown to be insufficient, and Brennecke's explanation 
covered only those cases where lasting congestion and consequent 
hyperplasia, with monorrhagia as a secondary result, occurred. 
Czempin recognised cases of severe monorrhagia unconnected 
with endometrial changes occurring in association with adnexal 



diseases. These, he suggested, might be due to an exaggeration 
of the normal stimulation, resulting in arterial congestion and 
consequent severe and lasting haemorrhage. Since the men- 
strual stimulus is associated essentially with an increased 
blood pressure, producing its effects in the uterus by creating a 
sudden hyperemia, it seems reasonable to suppose that an 
exaggerated stimulus should result in menorrhagia. 

The probability of disturbed ovarian function occurring at 
the menopause is readily appreciated, and the marked con- 
nection between the approaching menopause and uncontrollable 
uterine haemorrhage strongly suggests the possibility of ovarian 
changes being a causal factor in the haemorrhages. Cases of 
spontaneous cure occurring when ovarian activity ceases and 
the menopause is fully established, strengthen this possibility. 
Gardner and Gooclall, in a recently published paper, refer to 
such cases, and point out that if ovarian stimulation acting on 
a uterus affected by "chronic metritis" is the cause of the 
menorrhagia, then the menorrhagia should continue until 
ovarian function ceases, the condition of the uterus remaining 
unaltered. But they report a case where severe menorrhagia, 
occurring near the menopause and associated with all the usual 
signs of "chronic metritis," disappeared under conservative 
treatment, yet normal menstruation, indicating ovarian activity, 

It is interesting to note that several of the reported cases 
of uncontrollable haemorrhage laid to the charge of arterio- 
sclerosis or muscular deficiency have shown ovarian changes. 
Thus, in the case reported by Barbour, the right ovary was 
cystic, with very little ovarian substance left, while the left was 
small and sclerosed ; and of Anspach's three cases of " metror- 
rhagia myopathica," two showed ovarian changes to a slight 

Further, it is evident that impairment of the functional 
activity of the ovaries may occur independently of any demon- 


strable lesion, and may be the cause of haemorrhage in those 
cases where no pathological condition is found. Indeed, Freund 
goes so far as to say that only in cases of bleeding from car- 
cinoma has an anatomical basis for the haemorrhage been 

2. It is obvious, from a consideration of the part played by 
the musculature in the control of menstrual haemorrhage, that 
failure of the muscle to contract efficiently may be associated 
with haemorrhage of the severest kind. Such failure may be 
due to 

(a) actual deficiency of muscular tissue. Thus, insufficient 
muscular development, such as not infrequently obtains at the 
time of puberty ; or actual atrophy and degeneration, such as 
occurs normally at the menopause but may occur as a premature 
and so far pathological change; or "sclerosis" of the uterus, 
whether due to a primary diathetic condition (Brionde, Eichelot) 
or a secondary result of infection (Bland-Sutton), all come 
under this heading, and in all the muscular coat of the vessels 
participates in the pathological changes. Without actual 
deficiency of muscle, insufficient contraction may be due to 

(b) loss of tone in the musculature. This may occur as a 
simple atony associated with a lowering of tone throughout the 
body from some general cause, and possibly then accompanied 
by manifestations of muscular atony in other parts of the body, 
gastric symptoms, etc., or as a local change from the various 
causes, producing atony of the uterine muscle either directly or 
through fatigue of the nerve- cells. The effects of various 
poisons, of alcoholism, etc., on the nerve-cells has not yet been 
shown, but these have possibly a direct effect in producing 
atony of the musculaturei 

In cases of menorrhagia arising from this cause, intermen- 
strual leucorrhoea is a not infrequent symptom, the explanation 
being the lowering of tone in the vessel walls and the consequent 
ready escape of leucocytes. It is doubtful whether muscular 


insufficiency alone, apart from this element of lowering of tone, 
ever gives rise to leucorrhoea, since the capillaries in a healthy- 
condition have a remarkable power of resisting pressure, and 
accommodating themselves by enormous dilatation to an in- 
creased mass of blood. Typically, deficiency of the musculature, 
without deficient vitality of the vessel walls from loss of tone, 
will result in menorrhagia, the hemorrhage becoming more 
prolonged and profuse as the secondary hyperplasia of the 
uterine parenchyma becomes more evident. 

It is in this class that Theilhaber would place the great 
majority of the cases of uncontrollable haemorrhage occurring 
at the menopause, and in this he is enthusiastically supported 
by Palmer Findley. Normally, the regressive changes in the 
musculature associated with the menopause are accompanied by 
corresponding regressive changes in the blood-vessels which 
become accommodated to a decreased blood supply. Anything, 
therefore, preventing this normal diminution in blood supply, 
anything keeping the blood supply at its former level in face of 
the retrograde changes in the muscle, will cause haemorrhage — 
haemorrhage which these authors regard therefore as due to 
muscular insufficiency. But the regressive changes in the 
musculature are admittedly physiological, normal at the meno- 
pause, and would not give rise to haemorrhage were it not that 
the vessels are prevented from closing proportionately. It 
would seem more logical, then, to regard the haemorrhage as a 
result, not of the atrophied condition of the muscle, which is 
physiological, but of the patent condition of the vessels, which 
is pathological. It is evident that a normal blood supply acting 
on an insufficient musculature will have the same practical 
result as an increased blood supply on normal musculature. 
The question is whether the muscular atrophy is premature 
and therefore pathological, and justly to be blamed as the 
causal factor in the haemorrhage, or whether the blood supply is 
being maintained at a pathologically high level, either through 


failure to diminish when it naturally should, or from a real, and 
as yet unexplained, increase in pressure. 

Although many of the reported cases of intractable haemorr- 
hage show intermuscular fibrosis, with atrophy and degeneration 
of muscle, yet there is no general agreement that atrophy of 
muscle, beyond that occurring normally at the menopause, is 
characteristic. The point is extremely difficult to determine. 
Thus, in four cases reported recently by Wittek, three show 
intermuscular fibrosis, and the fourth does not. But the excep- 
tional case was a nullipara. Shaw, investigating cases of chronic 
metritis, finds no marked increase of connective tissue at the 
expense of muscular, but rather a hypertrophy of both elements, 
due, he considers, to efforts on the part of the uterus to rid itself 
of the thickened mucosa. 

Cases of haemorrhage where the musculature is insufficiently 
developed, or where its atrophy is definitely premature, are 
undoubtedly to be placed in the category of myopathic haemor- 
rhages. In this class also may justly be placed those cases which 
have as their starting-point an acute febrile disease such as 
typhoid ; or are associated with anaemic conditions, particularly 
chlorosis, or with chronic wasting diseases, such as phthisis. 
All these are definitely associated with changes in involuntary 
muscle, and show their effects, as a rule, on the heart. Other- 
wise, changes in the uterine musculature are probably for the 
most part secondary to circulatory disturbances. 

3. Cases of intractable uterine haemorrhage due primarily to 
circulatory disturbances form an important group. Continued 
congestion of the endometrium may be due to 

(a) an increased arterial supply. In determining this, the 
endometrium may be primarily at fault, as in cases of direct 
infection, placental retention where the remnants act the part 
of an irritant foreign body, and malignant disease of the mucosa. 
Inflammation and tumours of the adnexa, as also tumour 
formation, particularly fibro-myoma, in the uterus itself, will 



likewise determine an increased arterial supply, and to these 
may be added any local irritation, mechanical or psychical. 
Histologically, as Frennd has shown, this arterial congestion 
will be characterised by an increase in the number of capillaries, 
and a widening of the vessels, in which naturally the veins take 
part more readily and to a greater extent than the arteries, the 
widening in the veins being of a diffuse character affecting 
mostly the capillary venous network on which the strain of the 
increased blood supply first tells. 

(b) Venous obstruction may arise from a general condition, 
such as heart- or kidney-disease, chronic lung affections, chronic 
constipation, etc. ; or from local obstructions to the venous 
return, such as would be caused by tumours within or without 
the uterus ; or from displacements of the uterus. The resulting 
passive congestion does not, according to Freuncl, cause any 
increase in the number of capillaries, but results first in 
irregular dilatation of the larger veins, particularly of those in 
the fundus ; the pressure may further tell back on the arteries, 
and produce thickening of their walls. 

Long-continued congestion from whatever cause arising, 
brings about a very typical reaction in the mucosa. There 
appears to be little doubt that a large number of the cases 
variously described as " hyperplastic endometritis," " hyper- 
trophic glandular endometritis," " interstitial endometritis," etc., 
are simply, as Van Meerdervoort describes them, secondary 
results of long-continued congestion of the mucosa. The 
differences in the various forms, including "fungous" and 
" polypoid endometritis," are merely of degree, and he suggests 
" chronic oedema " as a more correct and appropriate title for 
the whole class. Lofquist arrives at very similar conclusions, 
suggesting that all the various changes are degrees of what he 
terms " decidual reaction." The changes are slow and gradual ; 
the distension of the capillaries does not result in haemorrhage, 
as in the more rapid menstrual increase in blood pressure, 


because the tissues have time to adapt themselves to the 
increased blood supply. Hyperplasia of the tissues results, 
affecting first the mucous membrane, and extending in the 
course of time to the entire uterus, giving one of the forms of 
" chronic metritis." 

Many attempts have been made to elucidate "chronic 
metritis," some observers regarding it as due always to infection 
of a more or less remote date, others as secondary to chronic 
endometritis, others as a primary condition giving rise to 
chronic endometritis by interference with muscular contraction 
and consequent hyperemia. That there are many forms of 
pathological change involved and so far confounded is probable. 
But one form of the affection — where the uterus is generally 
enlarged, with thickened walls showing no evident dispropor- 
tional increase in fibrous tissue, but rather a general swelling 
and hyperplasia of all the constituent elements, the endome- 
trium at the same time exhibiting one or other of the usual 
forms of "glandular endometritis" — is almost certainly due 
primarily to a disturbance in the circulation. This is the form of 
chronic metritis found in the various displacements of the uterus. 

Clinically, these cases are characterised by a gradually 
increasing monorrhagia, and this is what we should expect from 
the pathological condition. The menstrual stimulus, normally 
resulting in a comparatively rapid over-distension of the 
capillaries, produces its effect more slowly through the thickened 
mucosa with its already comparatively distended and more 
numerous capillaries, but when haemorrhage does occur, at the 
very height of the congestion, it is more profuse than normal 
because of the more widely distended condition of the capillaries. 
Similarly, the bleeding will last longer, partly from the lowered 
tone of the vessels from prolonged dilatation, and partly from 
inefficiency of the oedematous muscle, together resulting in less 
efficient response to the vasomotor stimulation, and so failure 
to arrest the haemorrhage with normal rapidity. 


But not all cases of venous congestion become clinically 
apparent as menorrhagia. Whether abnormal haemorrhage 
results, appears to depend to some extent on the resisting power 
of the endometrial capillaries. The vessels of the endometrium 
are peculiar. Macgregor has described them carefully, dis- 
tinguishing between the "thick-walled" and the "thin-walled" 
vessels. The latter are merely tubes lined by a single layer of 
delicate endothelium, and show enormous power of dilatation. 
The " thick-walled " vessels, on the other hand, derive support 
from a condensation of the stroma cells around them, and 
these, Macgregor states, while showing many changes in the 
way of thickening of their walls, hyaline degeneration, etc., 
never dilate. This is open to question. The thick-walled 
vessels, which it seems hardly correct to call " arterioles," may 
become dilated in cases of long-continued venous congestion. 
This was well shown in a recently observed case of retroflexion, 
in which there had been no abnormal haemorrhage. The 
mucous membrane was very markedly thickened, giving rise on 
curetting to the suspicion of malignancy, and its appearances 
were those of an advanced " chronic oedema," with great increase 
in the number of glands and swollen stroma cells showing their 
outlines and anastomosing processes in great perfection. Most 
striking was the large number of dilated " thick-walled " vessels, 
of globular outline and with a marked condensation of the 
stroma around them. The condition was produced in all 
probability by backward pressure from the long, over-distended, 
thin- walled capillaries, the healthy nervous tone of the capillary 
vessels preventing the relief of pressure by diapedesis. The 
patient in this case was comparatively young, 32, and unmarried. 
Where the congestion arises from an increased arterial supply, 
there is a tendency to metrorrhagia, in addition to the menor- 
rhagia commonly observed. Any sudden stimulation, mechanical 
or otherwise, determining a sudden further increase in the blood 
supply, may cause haemorrhage. We may suppose that the 


explanation is a sudden dilatation from vasomotor paralysis of 
the vessels formerly in a state of exaggerated tonus. 

Influence of the Menopause. — In determining the causal factor 
in any case of intractable uterine haemorrhage, therefore, many 
conditions must be considered. After excluding the cases 
probably arising from muscular insufficiency and eliminating all 
the usual causes of long-continued congestion, there still 
remains a class unexplained. Yet a careful consideration of 
the possible known causes markedly reduces the number of 
these obscure cases. Thus the patient whose case is reported 
by Pichevin and Petit, had had typhoid at 30, followed by 
menorrhagia, which was, however, cured by a supervening 
pregnancy, but returned in a severe form demanding hysterec- 
tomy after another pregnancy two years later. Again, of 
Pozzi's cases, while the elastic tissue proliferation on which he 
lays stress may mean nothing more, according to recent 
researches, than that the uteri examined were parous, one case 
had had typhoid, and the other had had chlorosis, and at the 
time of operation had albuminuria, an important symptom of 
increased blood pressure. It is of further interest to note that 
none of these patients was very near the menopause. 

Those cases becoming evident only at the menopause have 
probably their origin in circulatory troubles, the congestion 
having lasted perhaps for years previously without giving rise 
to any troublesome symptoms. 

We do not know how ovarian activity acts in maintaining 
the uterus in a healthy condition, but a twofold action at least 
suggests itself. The periodic vasomotor stimulation causing 
reflex contraction maintains the musculature in an efficient 
working condition ; and ovarian secretion in some obscure way 
preserves a healthy uterine tone. When ovarian stimulation 
begins to fail, the uterus suffers in this twofold way, so that 
there is a certain amount of atrophy from disuse, and a tendency 
to degeneration from the cutting off of some trophic influence. 


These effects will be equally produced in a uterus already 
affected by hyperplasia from continued congestion, and they 
are sufficient to determine the disturbance of compensation 
which results in monorrhagia. The menstrual stimulation is 
essential in starting the haemorrhage; the prevailing uterine 
conditions prevent its normal arrest. 

Pathological Changes in the Uterine Blood -vessels, and their 
Influence in Determining Hemorrhage. — So far the vessels have 
been dealt with as essentially part of the uterine musculature, 
and in no way to be regarded as of primary importance in the 
causation of haemorrhage. But arterio-sclerosis has been so 
extensively regarded as the causal factor that the subject deserves 
special attention. 

There can be no doubt that the vessel changes designated 
"arterio-sclerosis" are in many cases normal changes, and in 
no way to be regarded as responsible for the occurrence of 
uterine haemorrhage. Exactly similar changes are found un- 
connected with haemorrhage. Marked degenerative changes, 
designated by Anspach "periarterial" and "perivenous" de- 
generation occur normally in every parous uterus. In a 
specimen stained by haematoxylin and eosin these areas appear 
pink with few and scattered nuclei ; with Van Gieson's picro- 
fuchsin method they appear a brighter yellow, in clear contrast 
to the yellow of surrounding muscle; and with Weigert's 
resorcin-fuchsin stain for elastic fibres they take a dark blue or 
black colour. This definite increase in elastic tissue round the 
vessels is characteristic, and appears to occur during the puer- 
perium. The elastic tissue of the uterus generally is increased 
with every pregnancy, so that it is always possible to tell a 
parous from a non-parous uterus in a Weigert preparation. The 
fine elastic fibrils become thickened and curled, and show a 
tendency to clumping. In the vessels, the inner elastic lamina no 
longer appears as a clear, unbroken, wavy fibre, but is thickened 
and broken up, and there is an increase of elastic fibrils through- 



out the media. Melnikow-Easwendenkow believes that the place 
of lost parenchyma in any organ is taken by elastic tissue. Pick 
records a case of uterine haemorrhage resisting treatment in a 
woman of 63, which may have been due to an evident failure in 
the normal increase of elastic tissue around the uterine vessels. 

The normal involution of arteries after pregnancy is to be 
distinguished from a pathological change. Naturally there is 
enormous hypertrophy of the entire musculature in the gravid 
uterus, with new formation of blood-vessels, many of which 
must undergo entire obliteration during the process of involu- 
tion. This is brought about by a process recognised as 
"endarteritis obliterans," in which there may be enormous 
overgrowth of the intima, practically occluding the vessel; 
contraction of the new-formed connective tissue throughout the 
media and in the adventitia helps the process. Normally there 
is a slight increase of fibrous tissue at the expense of muscle 
when involution is completed ; the vessels share in this, their 
adventitial coats being relatively slightly thickened after each 
pregnancy. It appears, therefore, that thickening of the 
intima, with irregular increase in its elastic tissue, thickening 
of the media, with increase in the fibrous tissue of both media 
and adventitia; later, degeneration of the coats and of the 
surrounding tissue, with deposition of elastic tissue, may all 
occur as physiological changes. 

The following case, in which the uterus was removed on 
account of severe menstrual pain, and which is probably 
primarily one of glandular endometritis due to infection, the 
changes in the musculature being secondary, shows vascular 
changes which may be taken as physiological for a uterus with 
a corresponding history : — 

Mrs K., aged 36, was admitted to the Dundee Eoyal In- 
firmary on 4th December 1905. She had been married 
eighteen years, and has had nine pregnancies, the last five 


years ago. The first two pregnancies resulted in miscarriage 
at the third month, the third was normal, the fourth was 
premature (twins at the sixth month), the fifth ended in a 
miscarriage at the fifth month, the three following were normal, 
and the last ended in a miscarriage at the fifth month. Menses 
began at 14, occurring regularly every three to four weeks, 
unaccompanied by pain. She had some trouble which she 
described as a " growth of the womb " after the seventh preg- 
nancy, eight years ago, but this disappeared under treatment by 
" douches and medicine." Since the last pregnancy she has not 
felt well, and for more than a year has had severe menstrual 
pain, which has become much worse during the last two or 
three months. The pain lasts from two days to a week, beginning 
before the onset of the discharge; is worst for two or three 
hours after the onset, and continues after the flow ceases. The 
pain makes her sick. The discharge is normal in amount and 
character, and there is no intermenstrual discharge. She suffers 
from severe headaches and occasional frequency of micturition. 

On admission, she was found to be thin and pale, and as the 
physical examination gave rise to the suspicion of interstitial 
fibro-myoma of the uterus, hysterectomy was decided on. 

Operation. — ProfessorKynoch removed the enlarged uterus by 
the vaginal route. The patient made an uninterrupted recovery. 

Path. No. 4559. — The specimen consists of the uterus, which 
is generally enlarged, measuring, after hardening in alcohol, 10 J 
cm. x 5 cm. x 5 cm. On section, the uterine walls are seen to 
be thickened, and the endometrium to be strikingly thickened. 
The uterine cavity is 8 cm. long; the anterior wall at its 
thickest part measures 2J cm., and the posterior 2J cm. The 
mucous membrane shows a smooth undulating surface of a 
pinkish colour, and is of normal thickness in the cervix, greatly 
thickened just above the internal os, and less markedly 
thickened towards the fundus ; at its thickest part it measures 
on the anterior wall 7 to 8 mm., and on the posterior 9 to 10 mm. 


Histological Examination : Mucous Membrane. — The most 
marked change is the great increase in the number of the glands, 
a few of which are dilated. The glandular epithelium is 
swollen and oedematous. The stroma is loose and oedematous, 
and the vessels show marked condensation of the stroma 
around them. The junction between mucosa and muscle wall 
is strikingly irregular, glands penetrating the muscle to an 
unusual depth, and carrying with them strands of stroma 
(Kg. 1). 

Musculature. — The proportions of muscular and fibrous 
tissue appear about equal. The tissues are oedematous, the 
muscle nuclei appearing swollen, and patches of embryonic cells 
are seen throughout the musculature between the muscle 

Vessels. — The larger arteries are thickened in all their walls. 
The lumen is irregular in many cases, from projection of the 
media and occasionally of the intima. With Weigert's stain 
these irregular projections of the intima are seen to contain a good 
deal of elastic tissue, and the thickened inner elastic lamina is 
well shown, as also the deposition of elastic tissue in and around 
the degenerated adventitia. The intimal thickenings are shown 
to be almost entirely fibrous by Van Gieson's stain, and the 
degenerated areas around the vessels appear bright yellow. 
The media appears rather poor in nuclei, and the degenerated 
areas are almost free of nuclei, in a hgematoxylin preparation. 
The " periarterial " degeneration is very marked is some parts, 
especially in the smaller vessels near the endometrium (Fig. 1). 
Some of the arteries show a remarkable proliferation of the 
intima causing almost complete obliteration of the lumen. The 
veins show similar changes. There is an irregular proliferation 
of the inner coat, with an increase in fibrous tissue, and a 
thickening of the outer coat with degeneration extending into 
the surrounding tissues — "perivenous" degeneration (Figs. 6 
and 7). 



The case is of interest in several ways. The enormous 
hypertrophy of the endometrium in the absence of any tendency 
to haemorrhage, and the marked penetration of the glands into 
the underlying muscle without in the least suggesting a malig- 
nant process, are evidences that the primary trouble is in the 
endometrium. Cornil noted this penetration of the glandular 
elements as characteristic of chronic metritis. The cause of 
the pain is obscure. Possibly it was simply an exaggeration of 
the pain commonly experienced at the height of menstrual 
congestion: possibly the much thickened mucosa, acting as a 
foreign body, induced more severe contractions than normal 
in the endeavour of the uterus to expel the foreign body, and 
the increased blood pressure from ovarian stimulation in the 
premenstrual stage started the contractions, which became more 
severe as the congestion increased. The increase in the 
musculature may then be of the nature of a true " work-hyper- 
trophy." The existence of patches of embryonic cells throughout 
the entire muscle wall, but most commonly in its inner half, is 
noticeable, and suggests extension of an infective process from 
the endometrium. Probably the case is to be classified as one 
of chronic metritis, secondary to chronic infective endometritis, 
the musculature being as yet but slightly affected by the 
infective process. 

The senile changes occurring in the uterine vessels are 
illustrated in the following case : — 

Mrs D., aged 51, millworker, was admitted to the Dundee 
Eoyal Infirmary on 7th May 1906. She had had seven 
pregnancies, all normal, the last twenty-one years ago. Menses 
began at 13, and occurred regularly every twenty-eight days, 
lasting for two days, the discharge being scanty and accom- 
panied by slight pain ; the menopause occurred four years ago. 
For two years there has been a white discharge, fairly copious, 
and lately the discharge had been bloody at times. She had 


been in the Infirmary in the beginning of 1905, with symptoms 
of mitral incompetence, some chest trouble and diarrhoea 
suggesting enteritis, and again in February 1906, with gastro- 
intestinal symptoms. 

Physical Examination. — Patient is a worn-out old woman, 
and was intoxicated on admission. She has a slight cough; 
there are dullness and tubular breathing without accompani- 
ments at the left apex. There is a soft systolic mitral murmur. 
She complains of frequency of micturition. Examination under 
chloroform showed the cervix to be much shortened, the 
vaginal aspect normal except for small submucous haemorrhages. 
There was bleeding from the orifice. A swelling, possibly the 
fundus, was felt lying to the left; and, suspecting malignant 
disease of the body of the uterus, Dr Buist decided to do 
vaginal hysterectomy. 

Operation. — Dr Buist operated on 18th May. An incision 
was made in the posterior fornix and into the pouch of Douglas. 
A tumour mass was found on the left side, nodular, and not 
very mobile. The right broad ligament was crushed and 
divided, and the fundus brought down, when the uterus was 
seen to be small and senile, but otherwise apparently normal. 

The tumour mass could not be brought down, and median 
cceliotomy showed it to be in the sigmoid flexure of the colon 
with the left uterine appendages adherent. The adhesions 
were crushed and divided and the hysterectomy completed. 
The sigmoid tumour was isolated by Kenton's clamps and 
removed, and the bowel sutured end to end. 

The condition of the patient after the operation was never 
very hopeful, owing to the chest condition, and on the 21st an 
offensive vaginal discharge set in, becoming later putrid and 
black in colour, and death occurred on the 22nd. 

Path. No. 4750. — The specimen consists of the uterus, 
which is normal in contour but smaller than usual, measuring 
6 cm. x 3J cm. x 2| cm. The cervix appears normal save for a 


few subepithelial haemorrhages. The vessels entering the 
uterus are visibly thickened and prominent, and on section of 
the uterus the vessels stand out very distinctly in the vascular 
zone at the junction of the middle and outer thirds of the wall. 
Within this zone, extending into the mucosa, the muscular wall 
presents a curious, firm, homogeneous appearance. The mucosa 
is atrophied, and stained with blood in some places; its limits 
cannot be distinguished by the naked eye. The uterine wall 
measures 1J cm. in thickness, and is firm. 

Histological Examination : Mucous Membrane. — This is 
atrophied to a considerable extent, the glands persisting in 
groups between which fibrous tissue strands run right up almost 
to the surface epithelium. In many parts fibrous strands run 
along under the epithelium. The persisting glands are small, 
with swollen epithelial cells. There is considerable extravasa- 
tion of blood into the mucosa, while here and there red blood 
corpuscles may be seen making their way to the surface between 
the individual cells of the intact surface epithelium. The stroma 
is dense and its component cells are swollen and cedematous ; 
fibrous strands invade it in all directions. 

Muscular Wall. — The muscle is everywhere separated up 
by bands of fibrous tissue. The muscle shows evidence of 
degeneration and atrophy, its nuclei, especially near the 
endometrial surface, being swollen and degenerate-looking, and 
occasionally fragmented. 

Vessels. — The vessels occur in characteristic groups, with 
very narrow lumina (some appear entirely obliterated) and a 
wide area of degeneration surrounding them (Fig. 2). These 
areas are so extensive that neighbouring areas closely approach 
each other, and give a very striking appearance to the stained 
section, in which the degenerated tracts are readily recognised 
by the naked eye. The process is most marked in the middle 
third of the muscular wall (the homogeneous area). These 
areas stain darkly with Weigert's stain, although no definite 


structure can be made out in them (Fig. 3), and they appear 
bright yellow, in contrast to the yellow of the muscular tissue, 
in Van Gieson preparations, with an occasional remnant of red, 
fibrous tissue, persisting in the midst of the structureless yellow 
mass (Fig. 2). The larger vessels of the vascular zone show 
various degrees of thickening and degeneration of their walls. 
Many show calcification commencing between the intima and 
the media (Fig. 8). The intima is not particularly affected 
throughout; with Weigert's stain it shows a thickening and 
breaking up of the internal elastic lamina. There are irregular 
projections into the lumen in many cases, but these appear to 
be due mostly to an irregular proliferation of the media, over 
which the uniformly thickened intima extends. Both media 
and intima are degenerated, nuclei being very few and far apart. 
The adventitia is thickened throughout, and the degenerated 
areas in and around the adventitia stain deeply with Weigert's 
elastic stain. The increase in the adventitia appears to be due 
chiefly to elastic tissue, with which the media also is spun 
through, the elastic fibres again blending into a definite layer at 
the internal elastic lamina. The veins show similar changes. 
There is an increase of fibrous tissue in the inner coat, and a 
marked deposition of elastic t\ssu > e in the degenerated outer coat. 
There was thrombosis of a branch of one of the ovarian arteries 
where it entered the uterus at the broad ligament attachment — 
a thombosis evidently of ol^ ; landing, since there was organisa- 
tion with formation of new vessels in the midst of the thrombus. 
The senile change in this case was very advanced consider- 
ing the age of the patient, but the fact that when admitted to 
hospital she was in a state of intoxication, throws some light 
on the cause of the premature senility. From the histological 
examination, the case appears to have some points in common 
with those cases reported as " apoplexia uteri " by von Kahlden 
and others, where there was hemorrhagic infiltration of the 
endometrium, associated with sclerosis of the uterine arteries. 


Fig. 1. — Path. No. 4559. No haemorrhage. "Periarterial" degeneration in small 
vessels near the mucosa. Note also the unusually deep penetration of the glands 
into the muscle, and the cellular infiltration between muscle bundles. Hsema- 
toxylin and eosin. (x 50.) 

a, a\, Degenerate areas round small arteries, 

b, Glands penetrating 

[Inset, pages 104-105, 

Fig. 2.— Path. No. 4750. Senile case. Extensive "intramural" and "periarterial" degene- 
ration in vessels near the mucosa, with marked narrowing of lumina. Van Gieson. The 
degenerated areas stand out in sharp contrast to the surrounding tissue, which is exten- 
sively fibrous, (x 65.) 

a, a 1 , Narrow ring of fibrous tissue, remains of adventitia. 

Fig. 3. — Same group of vessels as shown in previous figure. Weigert's elastic stain. 
Note persistence of internal elastic lamina, and presence of elastic tissue, which 
appears black, in area corresponding to light (yellow) area in previous figure, (x 65.) 

a, Inner elastic lamina. 



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The occurrence of the leucorrhoea, beginning two years after 
the menopause, is undoubtedly to be associated with the dis- 
turbed compensation in the heart, which became evident about 
the same time. Later, the venous obstruction resulting from 
the sigmoid cancer added to the circulatory disturbance in the 
uterus, and the discharge thereupon became haemorrhagic and 
more troublesome and persistent. 

It is evident, therefore, that even very advanced premature 
senile change in the uterine vessels, with calcification in some 
of the arteries, and consequent rigidity, degeneration of vessels 
throughout the entire uterine wall, along with marked fibrosis 
of both musculature and endometrium, are all insufficient of 
themselves to cause serious haemorrhage, even in the presence 
of an incompetent heart. It is equally evident that in a normal 
senile uterus, an incompetent heart and venous obstruction 
such as would arise from cancer of the sigmoid flexure would 
not necessarily give rise to any uterine symptoms. The local 
condition determining the discharge in this case is probably 
the premature degeneration of the vessels, diapedesis through 
their degenerated and " toneless " walls, in presence of a sluggish 
arterial supply on the one hand, and venous obstruction on the 
other, being unusually easy. Alcoholism as a factor in bring- 
ing about this premature decay of the vessels is well known, 
but how the effect is produced is still obscure. The absence of 
the periodic menstrual stimulation in this case sufficiently 
accounts for the absence of sudden severe haemorrhages. 

Several cases have been reported where severe uterine 
haemorrhage was associated with general arterio-sclerosis. 
But this association does not simplify matters at all, except 
so far as to make it probable that the uterine arterio-sclerosis 
found was of a similar nature to the general change. 
Many cases of general arterio-sclerosis never show uterine 
haemorrhage. So in cases of bleeding where there is a history 


of syphilis many years previously. Syphilis we know to be 
one of the most common causes of general arterio-sclerosis. 
But by no means all cases of syphilis are attended by uterine 
haemorrhage. What determines the occurrence of the haemor- 
rhage in some cases ? 

The following case is of interest : — 

E. M., aged 50, unmarried, was admitted to the Dundee 
Royal Infirmary on 30th April 1906. One pregnancy (twins, 
six months) twenty years ago, since which time she has been 
blind (coloboma, chronic iritis, cataract). Menses began at 15, 
and occurred every three to four weeks, lasting seven days. 
Irregular bleeding began in November 1903, the first haemor- 
rhage lasting seven weeks, unaccompanied by pain, the second 
coming on after an interval of five weeks and lasting for four, 
and the third, after an interval of six weeks, lasting for five 
weeks, at which time she was curetted, the curettings showing 
nothing noteworthy. The physical examination at this time 
showed the os to be patulous, edges oedematous and slightly 
rough ; the fundus was nearly 3 inches above the symphysis ; 
there was slight tenderness in the left iliac region, and here the 
left tube could be palpated as a smooth, fairly firm, elastic oval 
swelling. There was uterine haemorrhage on manipulation. 
The bleeding recommenced eleven days after the curettage, and 
recurred at intervals up to the time of admission, the last 
haemorrhage having begun two months before admission, and 
continued up to that time. 

Physical Examination. — Patient is very weak, giddy, and 
faint. There is slight pain all over the abdomen. She is pale, 
with dilated capillaries on the cheeks. Pulse 104, of "water- 
hammer " variety ; and examination of the heart shows presence 
of aortic systolic and diastolic murmurs. 

Operation. — Hysterectomy was performed by Dr Buist a 
week after admission. A perivaginal incision was made, and 


a roughly " banana-shaped " hydrosalpinx of the left side 
removed, clear fluid escaping. The left ovary, which was 
slightly cystic, was crushed and removed; and the normal 
right ovary was left. The patient died on the second evening 
after the operation, and the post-mortem examination showed 
widening of the aorta, with some atheroma; the kidneys con- 
tracted and unequal in size, and the liver fatty. 

Path. No. 4738. — The specimen consists of the uterus, and 
the cystic left tube. When inflated the tube appears roughly 
to be equal in size and similar in shape to a banana, with an 
extremely thin, smooth, transparent wall. 

The uterus is of normal contour, but generally enlarged; 
the serous surface is smooth and free from adhesions. The lips 
of the cervix are somewhat hypersemic and very slightly 
nodular; the cervix is 3 J cm. broad, and shows a transversely 
oval aperture measuring 1J x 1 cm. The uterus measures 
9 \ cm. x 5 \ cm. x 4 J cm. ; the cavity from fundus to external 
os measures 7J cm. ; in breadth, from the centre of the canal 
outwards in the direction of the right cornu, it measures 1J cm., 
but in the direction of the left cornu, owing to the hydrosal- 
pinx, is reduced to f cm. The muscle appears normal, though 
very pale, and the blood-vessels appear distinctly on the cut 
surface. The mucous membrane is uniformly smooth and 
pale, measuring 1 to 2 mm. in thickness on the anterior wall, 
which itself measures 2 J cm. 

Histological Examination : Mucous Membrane. — The surface 
epithelium is intact and smooth throughout the greater part 
of the cavity; towards the fundus it shows a tendency to 
become polypoid. The glands are not increased in number, but 
appear larger than usual, with very markedly swollen epithelial 
cells. The stroma is oedematous, and its cells swollen, and 
many large dilated blood spaces lined by a single layer of 
endothelium are to be seen just beneath the surface epithelium. 
The thick-walled capillaries appear normal in many cases, but 


some are thickened by condensation of the stroma around 
them, and one or two show hyaline degeneration (Fig. 13). 
Vessels having definite fibrous and muscular walls are found 
within the mucosa, occurring often quite close to the glands 
(Fig. 12), and in sections stained by Weigert's stain for elastic 
fibres, these show a well-marked inner elastic lamina. 

The junction between mucosa and muscle is sharply 
marked, and here the number of dilated lymphatic spaces and the 
numerous groups of vessels with thickened walls are striking. 

Muscular Wall. — The muscle appears on the whole well- 
preserved. There is no marked increase in the amount of 
fibrous tissue, but in some parts the fibrous tissue which 
throughout the specimen penetrates between the individual 
muscle fibres, appears to have increased and produced atrophy 
of the enclosed muscle fibres. No broad bands of fibrous tissue 
are to be seen in the specimen except such as form the adven- 
titial coats of the larger vessels. The fibrous tissue throughout 
shows a tendency to degenerate. 

Vessels. — The larger vessels in the vascular zone show a 
marked thickening of all their coats. In the arteries, the 
intima, as a rule, is irregularly thickened, forming definite pro- 
jections into the lumen in some cases. In sections stained by 
haematoxylin and eosin, the thickened intima is seen to be poor 
in nuclei and more or less degenerated ; with Van Gieson's 
stain there appears a considerable increase in fibrous tissue 
which is markedly degenerated; while Weigert's elastic 
stain shows a definite increase in elastic fibres throughout the 
intima in many of the larger arteries. This is strikingly seen 
in a branch of the uterine artery at its point of entrance to the 
uterine wall (Fig. 14). The media also in this vessel is greatly 
thickened, and while the muscle nuclei are fairly well pre- 
served, as seen in a haematoxylin preparation, there are signs 
of atrophy of the muscle in parts. The muscle fibres are seen, 
in a Van Gieson preparation, to be interpenetrated by i 


degenerating fibrous tissue, which apparently presses on 
and destroys the muscle cells. This is also to be seen in 
the arteries within the uterine wall, though to a much less 
extent; the usual condition is a hypertrophy of the media 
without evident degeneration. The adventitia is thickened 
and degenerated in the larger arteries, appearing in Van Gieson 
sections as a grandular red or pink mass, and not taking 
Weigert's stain. The veins do not show much change from 
the normal. In some cases both coats are thickened, the inner 
showing irregular proliferation filling up the lumen, and the 
outer showing an increase in elastic tissue, which also extends 
in fine fibrils through the inner coat. The smaller arteries 
show swelling of the endothelial cells as a rule, or slight 
irregular proliferation of the intima ; slight thickening of the 
media ; and marked thickening in the adventitia (Figs. 9 and 
10). The groups of vessels so affected occurring amongst the 
glandular tissue at the junction of mucosa and muscle are 
particularly striking (Fig. 11). 

Cervix. — There is a cystic condition of some of the glands, 
and here and there a subepithelial hemorrhagic infiltration. 
The vessels are slightly thickened in all their coats, but there is 
no marked increase in the elastic tissue. The arteries retain 
their well-marked internal elastic lamina, which appears 
thickened only in one or two of the larger vessels. 

It is noticeable that in this case there is no typical 
"periarterial" or "perivenous" degeneration. The degenera- 
tion here is in the fibrous tissue of the thickened adventitial 
coats, the degenerated areas looking pink and granular with 
Van Gieson's stain, and not staining at all with Weigert's. 
So far, it might appear that there is a failure in the normal 
increase in elastic tissue. But, on the other hand, there is, in 
the larger vessels particularly, a definite increase in elastic 
tissue in the intima; and the uterus in this case had been 
only once pregnant. The possibility of infection must not be 


overlooked, since there was evidence of adnexal inflammation. 
Addinsell describes degeneration of the fibrous tissue as the third 
stage of the pathological process in " chronic infective metritis." 

Certainly failure of increase in the elastic tissue will not 
explain the haemorrhage in another case examined, that of a 
woman, aged 45, with a history of severe monorrhagia for ten 
years, and in whom death suddenly occurred three months 
after curetting, from septic peritonitis, evidently originating 
from an acute endometritis (Path. No. 2505). The vessels 
show marked and extensive degeneration within and around 
their walls (Fig 4). The intima is not markedly affected, but 
the media in most of the larger arteries is very greatly thickened 
and degenerated ; and in the most advanced cases both media 
and adventitia are represented in Weigert sections as solid 
clumps of elastic tissue (Fig. 5). The veins have thickened 
inner coats of well-formed fibrous tissue, and show an increase 
in elastic tissue in their outer coats, in the position occupied 
by degenerated areas of few nuclei in hematoxylin and eosin 
preparations. The vessel condition is practically identical with 
that found in the senile case already described, although the 
changes have not extended to the smaller vessels to the same 
extent. The musculature in this case is separated up by bands 
of fibrous tissue, which is well formed and not degenerated. 
The cause of the menorrhagia is not evident. 

Is there, then, an arterio-sclerosis of the uterine vessels 
apart from that brought about by physiological causes ? If so, 
will the condition necessarily be accompanied by hemorrhage ? 

If we consider how the physiological changes are brought 
about, the question becomes clearer. Westphalen and Thoma 
have endeavoured to show that the peculiar vessel changes in 
the uterus are essentially due to the changes in blood pressure 
to which the functionally active uterus is subject. The periodic 
increase in blood pressure at the menstrual periods, and still 
more the pressure changes incident to pregnancy and thfl 


puerperium, cause changes in the uterine vessels to which no 
other vessels in the body are subject to the same extent. The 
uterine vessels are, so to speak, shorter-lived than any others. 
If, now, it be supposed that changes in blood pressure in these 
arteries arise from some pathological condition, apart from 
pregnancy, etc., similar changes will presumably occur. 

Theoretically, we may suppose that persistent high tension 
in the uterine and ovarian arteries will bring about as a first 
result, through increased vasomotor stimulation, an exaggerated 
response on the part of the musculature, so that a true " work- 
hypertrophy" takes place, i.e., hypertrophy of the uterine 
muscle generally, including the muscular coats of the arteries. 
Since arteries acquire their coats in proportion to the pressure 
they are called on to resist, it is probable that the adventitia 
will be strengthened by an increase in fibrous tissue. The 
strain must necessarily tell on the intima. In all parous uteri 
the inner elastic lamina of the arteries is thickened. In the case 
described, where general arterio-sclerosis was present, the 
larger arteries showed a marked increase in elastic tissue in the 
intimal coats. Probably this is the nature of the compensatory 
change when the artery wall is subjected to a sustained increase 
in blood pressure. Later the continued pressure will bring 
about degenerative changes ; in the intima, whose nuclei dis- 
appear to a great extent; and in the media, where fatty 
degeneration and atrophy of the muscle may occur. We may 
further suppose that if the increase in pressure be gradual and 
sustained, as would occur in a case associated with general 
arterio-sclerosis, the compensatory change will extend gradually 
to smaller and smaller branches of the vessels, reaching eventu- 
ally the endometrial capillaries. When degenerative changes 
have occurred, and the vessels can no longer react to the 
increased blood pressure, in other words, when compensation 
is disturbed, haemorrhage will result. The importance of 
menstruation in starting the haemorrhage has already been seen. 


All these changes are illustrated in the case described 
above, in which there was general arterio-sclerosis, and a fairly 
clear history of syphilitic infection dating back twenty years. 
The peculiar pathological features in the case are — (1) the 
very distinct affection of the intima, which showed irregular 
proliferation and an increase in wavy elastic fibres out of all 
proportion to the general elastic increase, whixm was only very 
slightly marked, throughout the uterus ; (2) the marked fibrosis 
around the vessels, particularly the smaller vessels, unassoci- 
ated with fibrosis of the uterus generally ; (3) the occurrence 
of groups of thickened vessels at the junction of mucosa and 
muscle, and the tendency of these vessels to invade the mucosa ; 
(4) the existence of vessels with definite walls and a well- 
marked internal elastic lamina within the mucosa, and thicken- 
ing and degeneration of the " thick-walled " endometrial 

The case is clearly one of uterine arterio-sclerosis associated 
with general arterio-sclerosis. A clear case of pathological 
uterine arterio-sclerosis existing as a purely local condition has 
yet to be demonstrated. 

The changes in the vessels due to physiological processes 
cannot be regarded as causes of haemorrhage. They may go to 
an extreme degree without the occurrence of any abnormal 
bleeding. This is only natural. Further, since these changes 
are essentially brought about by the changes in blood pressure 
associated with the functionally active uterus, they are possibly 
indistinguishable from changes due to a pathological increase 
in blood pressure. In the causation of haemorrhage, the import- 
ant thing is the pathological increase in blood pressure which 
gives rise to the vessel condition. To speak of the arterio- 
sclerosis as the cause of the haemorrhage is a mere confounding 
of words. The haemorrhage is a symptom of the condition of 
which the arterio-sclerosis is a sign. The association between 
hyperpiesis and arterio-sclerosis in other parts of the body is 

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Fig. 8.— Path. No. 4750. Senile case. Calcareous degeneration beginning in 
superficial layers of media in large artery, (x 30.) 

a, Intima. b. Media, c, Calcifying area. 



'. g <D 1 « x 

Fig. 11.— Same case as Figs. 9 and 10. Group of thickened vessels occurring 
just under the mucous membrane. ( x 90.) 

a, Mucosa, a 1 , Detached glandular epithelium, b, Muscle. 

Fig. 12. — Same case as above. Weigert. Small vessels with definite walls and well-marked^ 
internal elastic laminse occurring within the endometrium. ( x 200.) 

a, a 1 , Unstained glandular epithelium, b, Unstained stroma of mucosa, 
c, c 1 , Inner elastic lamina. 

Fig. 13.— Same case as above " Hyaline " degeneration of an endometrial capillary. 
Note the circular arrangement; of the stroma round the vessel. ( x 230.) 

Fig. 14.— Same case as above. Irregular proliferation of intima in a branch of 
uterine artery where it enters the uterus. . Hematoxylin and eosin. 

a, Intima. b, Media, c, Adventitia. 

U c3 




well known though not clearly understood. It seems clear in 
some cases that the increased blood pressure precedes the 
change in the vessels and is the cause of it, although the case 
is complicated by the fact that the vessel change may itself 
induce a rise in blood pressure by increasing the peripheral 
resistance. The real difficulty is that the aetiology of arterio- 
sclerosis occurring anywhere in the body is still obscure. 
After all the well-established causes, including syphilis, 
alcoholism, various forms of poisoning, etc., have been excluded, 
there remains a class of unexplained cases arising independently 
of these causes in comparatively young people, and associated 
in some way with an increased arterial tension. Similar con- 
ditions may arise in the uterus, possibly associated with some 
form of local toxaemia. But the essential point is the condition 
behind the vessel change. It is readily conceivable that if an 
increase in arterial pressure occurred suddenly, or occurred in a 
uterus of deficient musculature, haemorrhage of a severe kind 
might occur before any marked changes in the vessels had had 
time to occur. Thus Simmonds' case of uncontrollable haemor- 
rhage showed a sclerosis of the uterine artery alone. At the 
opposite extreme are those cases where the changes have 
extended to the vessels of the endometrium, and where the 
diagnosis can be made from curettings. 


1. Addinsell (A. W.). — " Chronic Infective Metritis," Journ. 

Obst. and Gyn. Brit. Empire, July 1906, vol. x., No. 1. 

2. Anspach (B. M.). — "Metrorrhagia Myopathica," Amer. 

Journ. Obst., Jan. 1906. 

3. Bandler. — " The Ovary : its Eelations to Normal Functions 

and to Pathological States," Med. Record, 1901, p. 405. 

4. Barbour (A. H. R). — "Climacteric Haemorrhage due to 

Sclerosis, etc.," Obst. Trans. Edin., vol. xxx., p. 71. 



5. Bland-Sutton. — Brit. Med. Journ., 1899, vol. i., p. 840. 

"Fibrosis of Uterus," Brit. Med. Journ., 1904, vol. 

ii., p. 1072. 

" 100 Hysterectomies, etc.," Lancet, 27th May 1905, 

p. 1406. 

6. Boldt (J. H.). — " Cavernous Angioma of Uterus," Amer. 

Journ. Obst., Sept. 1893. 

7. Berissoff (A.). — "Ueber die Veranderung der Uterus- 

schleimhaut bei Fibromyomen in Zusammenhange mit 
Uterusblutungen," Monats. fur Geb. und Gyn., vol. ii., 
pt. 5, p. 351. 

8. Brennecke. — "Zur Etiologie der Endometritis fungosa," 

Archivfilr Gyn., 1884, vol. ii., p. 455. 

9. Brionde. — "De la sclerose de l'uterus," La Gyn., 1896, vol. i. 

10. Cholmogoroff. — "Sklerose der Uterusarterien," Monats. 

fur Geb. und Gyn., vol. ii., p. 692. 

11. Cornil. — "Lecons sur l'anat. pathol. des metrites, etc." 

Paris, 1889. 

12. Dickinson (R L.). — "The Intractable Menorrhagias of 

Arterio-sclerosis of the Uterus," Brooklyn Med. Journ., 
Feb. 1906, vol. xx„ No. 2. 

13. DolfIris (J. A). — "Troubles ut6rins d'origine degenerative," 

La Gyn., April 1901 and June 1901. 

14. Dunning (L. H.). — "Acute Senile Endometritis," Journ. 

Amer. Med. Associa., 3rd Nov. 1901. 

15. Findley (Palmer). — "Arterio-sclerosis of Uterus," Amer. 

Journ. Obstet, 1901, vol. i., p. 30. 

" Arterio-sclerosis of the Uterus as a Causal Factor 

in Uterine Hemorrhage," Amer. Journ. Obstet., July 
1905, p. 71. 

16. Freund. — " Zur Lehre v. d. Blutgefassen der normalen und 

kranken Gebarmutter." Jena, 1904. 

17. Gardner and Goodall. — "Chronic Metritis and Arterio- 

sclerotic Uteri," Brit. Med. Journ., 3rd Nov. 1906. 


18. Gottschalk. — "Eine besondere Art. seniler, hamorrhagi- 

scher, leukocy tarer Hyperplasie der Gebarmutterschleim- 
haut," Archivfilr Gyn,, vol. lxvi., 1902, p. 169. 

19. Grube. — "Ueber unstillbare Uterusblutungen und Art. 

Sklerose, etc.," Centralbl fur Gyn., 1902, p. 673. 

20. v. Kahlden. — "Ueber die sogenannte Apoplexia Uteri," 

Ziegler's Beitr., 1898, vol. xxiii., p. 161. 

21. Ketffer. — " Histology of the Nervous System in the Uterus," 

Bull, de la Soc. Beige de Gyn. el d'Obst., vol. xi., No. 5. 

22. Klob. — " Pathol. Anat. der weiblichen Sexual-organen," 

p. 173. 

23. Kustner. — " Die Behandlung der post-partum Blutungen," 

Deut. med. Woch., 1890, p. 5. 

24. Lofqvist. — "Zur Pathologie der Mucosa corporis uteri." 

Berlin, 1903. 

25. Macgregor (Jessie M.). — " Pathology of the Endometrium," 

2G. Marchesk— Arch. d'Obst. et Gyn., 1897. 

27. Martin. — Path, und Therapie der Frauenkrankheiten, vol. i., 

p. 994. 

28. Meerdervoort (Pompe v.). — "Anatomie de la Pseudo- 

endometrite," Bevue de Gyn,, 1902, vol. vi., p. 227. 

29. Melnikow-Kaswendenkow. — Zieglers Beitr. zur path. 

Anat. und allgem. Pathol., vol. xxvi. 

30. Mullerheim.— "Arterioskleros. Uter.," Zeits. filr Geb. und 

Gyn., vol. xxxvi., p. 355. 

31. Pichevin et Petit. — " Metrorrhagies et lesions vasculaires 

de Puterus," Gaz. Med. de Paris, 1895, p. 553. 

32. Pick. — Volkmann's Sammhmg Minischer Vortrage, Nr. 283. 

33. Pierra. — " Primary Uterine Congestion in neuro-arthritic 

Patients," La Gyn., June 1904. 

34. Pozzi et Latteux. — "Sur une forme rare de nitrite 
hemorrhagique," Revue de Gyn., 1889, vol. iii., p. 


35. Eeinecke. — " Die Sklerose der Uterinarterien unci die 

klimakt. Blutungen," Archiv fur Gyn., vol. liii., p. 

36. Richelot et Bakozzi. — " Scleros. uter. et la vrai metrite," 

La Gyn., Paris, 1901. . 

37. Saville.— Brit. Med. Journ., 1896, vol. ii., p. 713. 

38. Shaw (W. F.).— " Chronic Metritis : its Pathology and its 

Relation to Chronic Endometritis," Thesis, Manchester, 

39. Simmonds. — "Ueber Hamorrh. d. Endometr. bei Sklerose 

der Uterus-arterien," Centralbl. filr Gyn., 1901, No. 3, 
p. 81. 

40. Siredey (A.). — "La metrite parenchymateuse chronique," 

La Gyn., Feb. 1902, p. 1. 

41. Theilhaber. — "Die Ursachen der praklimakterischen 

Blutungen," Archiv filr Gyn, 1901, vol. lxii. 

und Meier. — " Die Variationen, im Bau des Mesome- 

trium, etc.," Archiv filr Gyn., 1902, vol. lxvi. 

"Die sogenannte chronische Metritis, etc.," Archiv 

filr Gyn., 1903, vol. lxx. 

42. Westphalen. — " Zur Physiologie der Menstruation," Archiv 

filr Gyn., vol. Hi., p. 35. 

43. Wittek (Kurt). — " Die sklerotischen Gefassveranderungen 

des Uterus, etc.," Monats. filr Geburts. und Gyn., 1906, 
vol. xxiii, p. 796. 

The President conveyed to Dr Macdonald the thanks of the 
Society for bringing this piece of work before them. Her paper 
was a most thorough, a most scientific, a most academic dis- 
cussion of the subject. It was a difficult subject, and Dr 
Macdonald had tackled it in a thoroughly scientific way. It was 
also a difficult paper for them to discuss, because the questions 
raised in it were, many of them, novel and somewhat complex. 


It seemed to him that, apart from the purely scientific way of 
presentation, the practical view came to be that the uterus at 
the menopause became very rapidly old; that the uterus, so 
to say, might be 70 while the patient herself was still between 
40 and 50; and that in the ageing of the organ the vessels 
might become old before the rest of the uterus. It occurred 
to him that it might be found that the same sort of changes 
occurred in the placenta in cases of accidental haemorrhage 
where there was no traumatism. It would be a very good sup- 
plement to her work to compare this condition in the uterus 
with a placenta of that kind. He himself thought that in 
looking over these microphotographs, he had seen sections of 
placentae that closely resembled them. 

Dr Haultain seconded the President's eulogy on the very 
excellent paper which Dr Macdonald had given them. The 
subject was very wide, and one they could not discuss in its 
entirety. There were one or two important practical points 
which had been brought before them. In the first place, there 
could be no doubt that haemorrhages from the uterus might 
be threefold — endometric, ovarian, and from the uterine wall. 
The endometric variety, which they all knew so well, with the 
capillary changes and so on, and which naturally could be cured 
in the majority of cases by curetting. It was perhaps with the 
other two varieties that the paper dealt more particularly. 
With regard to the ovarian variety, there was no reasonable 
doubt that the ovary had a strong influence on uterine haemor- 
rhage. From time to time they met with cases in which the 
ovary and it alone was the cause of uterine haemorrhage. Some 
years ago, before hysterectomy was such a common operation, 
the removal of the ovaries was undertaken for severe intractable 
cases of haemorrhage for which curetting would not do any 
good. It struck me that in several cases bleeding still continued 
after the removal of the ovaries ; although in the majority of 
cases monorrhagia and metrorrhagia frequently were cured by 


the removal of the ovaries, which made it certain that there 
was an important ovarian influence. But it was in these cases 
where, after the removal of the ovaries the bleeding continued, 
in which there was some condition in the uterine wall, or the 
vessels penetrating that wall, which gave rise to the condition. 
He had had upon five occasions to remove uteri for that condition, 
where there was no malignancy, where the ovarian condition, 
as far as one could see, was perfectly normal, but where in 
spite of persistent curetting, and in one case in spite of the 
removal of the ovaries, the bleeding had continued. Three of 
these cases were in young women under 25. In the other 
two cases the women were well past the menopause. The 
condition found in four of these was almost identical — a 
very considerable arterio- sclerosis, and in three of these very 
considerable thickening of the uterine wall, analogous to that 
found in so-called fibroid and in subinvolution. Further, in 
making some investigations in fibroids, one found in a consider- 
able proportion of fibroid uteri, that this condition of the blood- 
vessels existed. It seemed to him that possibly this accounted 
for those cases where, after the removal of the ovaries, there was 
still bleeding from a fibroid uterus. Post-climacteric haemorrhage 
could go on in a uterus already afflicted with fibroid disease. 
There was certainly a class of case where nothing but removal 
of the uterus could cure the condition, which might be not 
only post-climacteric, but might occur in a very young woman. 
And it seemed to him a far better operation in young women 
in whom curetting did not cure the condition, and where the 
patients were invalided, to remove the uterus and leave the 
ovaries, than to remove the ovaries and leave the uterus; 
because in the former cases the ovarian influence was not 
removed, and the removal of the uterus itself did not seem to 
act in the same way as removal of the ovaries, for it was an 
organ which did not appear to have an internal secretion. 

Dr Ritchie said he had listened with very great interest to 


the paper. Dr Macdonald's opinion seemed to him to be that 
the arterio-sclerosis was practically a physiological change in 
aged uteri, and that haemorrhage did not arise quite so much 
from changes in the vessels as from what was behind them. 
He asked Dr Macdonald to state in her reply whether this was 
the opinion which she advocated. 

Dr B. P. Watson said he could not offer the explanation Dr 
Fordyce desired. As to the particular uterus which Dr Barbour 
had described and which he had had the pleasure of examining, 
the vessel changes in it were very much the same as Dr Mac- 
donald had described. The vessels of the mucous membrane 
were specially affected, and showed great thickening of the walls 
and hyaline degeneration. There was no arterio-sclerosis of 
any other vessels, and no history of any cause likely to produce 
the condition. One ovary was cystic, but no other abnormality 
was present. He said the paper had been a most interesting 
one, and the microphotographs shown were very clear, so that 
he would have liked to have seen the actual sections, which 
must be very fine. 

Dr Porter said he was not competent to discuss the paper, 
but expressed his pleasure at having heard it read. He 
inquired whether there was any history of haemophilia in any 
of the cases. 

Dr Elizabeth Macdonald, in reply, thanked the Fellows for 
the way in which they had received the paper. In reply to Dr 
Eitchie, she said she did take up the attitude that the vessel 
changes were of secondary importance in the causation of 
haemorrhage. She had come to this conclusion from a con- 
sideration of the case of premature senile change, where the 
vessels were extensively degenerated, and where there was no 
haemorrhage to speak of. As to septic infection causing the 
vessel changes, there was no doubt that it was one of the most 
general causes of vessel degeneration. But in the case quoted 
the patient had suffered from monorrhagia for ten years, and 


the infection had been quite a recent one, not lasting for more 
than three months, so that it could not in this case explain 
the monorrhagia of twenty years' standing. 

Meeting IV. — February 9, 1907. 
Dr J. W. Ballantyne, President, in the Chair. 

I. The following ladies and gentlemen were elected Ordinary 
Fellows of the Society:— Mary C. Hamilton, L.R.C.P. & S.E., 
L.F.P.S. Glas., Sick Children's Hospital, Edinburgh ; Elsie M. 
Barnetson, M.B., Ch.B., 31 Morton Street, Joppa ; J. A. MacLeod, 
M.B., Ch.B., Royal Maternity Hospital, Edinburgh ; H. S. Reid, 
M.B., Ch.B., Royal Maternity Hospital, Edinburgh. 

II. The President showed — (a) A PAIR OF cystic kidneys 
from a foetus. There had been some difficulty with the labour, 
and the child was still-born. Only a very rapid post-mortem 
examination was permitted, and the liver and both kidneys were 
found to be enlarged. The kidneys only were removed; each 
weighed over 4 ounces, and one was 10 cm. long and the other 
9 \ cm. — about three times the normal size. There was not very 
much to be made out on naked-eye examination, save a general 
spongy appearance, but under the microscope the kidney tissue 
was seen to consist of hundreds of thousands of small cystic 
cavities. These kidneys are supposed to be not really cystic, 
but a form of adenomatous degeneration, and so are really to be 
classed as tumours rather than cystic degenerations, (b) Frozen 
sections of A female fcetus, born in Maternity last September. 
At birth it was thought to be normal, but when Dr Ballantyne 
was going round the ward the next day he noticed that the 
child was carrying its head very low on its shoulders, and 


ventured a diagnosis of cervical spina bifida, though there was 
no external indication thereof. It died in a few days, and the 
specimen showed very well the condition of hidden cervical 
spina bifida. 

III. Br Barbour showed — (a) A fibrous tumour of ovary, 
so wedged in pelvis and pressing against uterus that a diagnosis 
of uterine tumour was made. There were pressure symptoms on 
the rectum, and there was difficulty at the operation in pulling 
the tumour past the promontory. (6) Euptured ovarian cyst, 
with pseudo-myxoma peritonei. The cyst contained gelatinous 
material. The omentum was hanging down like an apron, 
infiltrated with this tissue, (c) Dermoid tumour of ovary, 
with a twisted pedicle. The tumour had been diagnosed as a 
fibroid of ten years' duration, and during that time it had not 
produced any symptoms. The patient was suddenly seized 
with symptoms partly suggestive of torsion of the pedicle, but 
instead of sickness there were symptoms of obstruction of the 
bowels, which was found on operation to be due to paralysis 
of the bowel, the result of commencing peritonitis. There was 
difficulty in overcoming the paralysis of the bowel for two or 
three days, but the patient did very well. 


By F. W. N. Haultain, M.D., F.R.C.P. Ed., Physician for Diseases of 
Women, Deaconess Hospital, Edinburgh. 

As is well known, the cervix and body of the uterus essentially 
differ in their anatomical aspects from the earliest periods of 
the development of the organ. These striking differences they 
maintain throughout the life of the individual, not only in 



their anatomical, but also in their physiological and pathological 
features. Upon such it is not necessary to dwell, except in the 
essential particular which is associated with the development 
and growth of uterine fibro-myomata, which forms the text of 
the following observations. 

The development and growth of these tumours in the 
cervix is rare, and is said to account for about 5 per cent, only 

Fig. 1. 

of all cases of uterine fibro-myomata. In this connection my 
operative experience is not in strict accord, as out of 260 cases 
of hysterectomy for these neoplasms, I have on thirty occa- 
sions met with their primary development in this situation. 
But when the large number of corporeal fibro-myomata I have 
seen, in which operative treatment was unnecessary, is con- 
sidered, this percentage may fairly be taken as about the 
normal. At the same time, it must be remembered that 


submucous cervical fibroids aud interstitial tumours of the 
intravaginal portion are by no means rare, and are removable 
through the vagina. 

Divisions of Cervix. — To study and classify these growths 
one must take into account the anatomical description of the 
cervix into three portions — supravaginal, inter vaginal, and 
intravaginal, which is of such great importance in the descrip- 
tion of hypertrophic conditions. These may be described as 
being differentiated from one another by the attachment of the 
vaginal walls ; the " intra " being below the attachment of the 
anterior vaginal wall, the " supra " being above the attachment 
of the posterior wall, and the " inter " the intervening portion 
between these two (Fig. 1). Tumours of the intravaginal 
portion alone do not here call for description, as their removal 
by the abdominal route, or indeed the removal of the 
uterus, is uncalled for, and they may thus be dismissed. I 
therefore confine myself to those associated with the intervaginal 
and supravaginal portions with subsequent involvement of the 
intravaginal portion. 

1. Table of cases in which cervix alone ivas involved — 

(a) Supravaginal portion . . {^fir' 1} 4 ] 

(b) Supravaginal and intervaginal /Posterior 4\ A^ 

portion [Anterior 2| 

(c) Supravaginal, intervaginal, /Posterior sl-.^ 

and intravaginal portions (Anterior 4 J - 

2. Cases complicated with corporeal fibroids . 7 7 

3. Case complicated with one month's pregnancy 1 1 


The supravaginal tumours were more of the subperitoneal 
type, and, with one exception, grew from the posterior wall, 
and embedded themselves downwards in the recto-vaginal 
septum. They thus bulged the posterior vaginal wall forwards, 



but in no way affected the free portion of the cervix, except 
that it was displaced high up behind the pubis, and was diffi- 
cult to reach. 

Six supravaginal and intervaginal growths were met with, 
two in the anterior and four in the posterior wall. As the 
result of the want of involvement of the intravaginal portion, 
the external os was in no way affected, and remained as a 
slight projection on the base of the tumour, with a small open- 
ing at its tip (Fig. 2). All these tumours were sufficiently 

Fig. 2.— Fibro-myoma involving supravaginal and intervaginal portions of cervix 
anterior wall. Dotted line shows peritoneum. 

large to fill the brim of the pelvis, and grew upwards and 
downwards, assuming the typical ovoid shape. The bladder in 
all instances was displaced upwards into the abdomen — in the 
anterior tumours by the actual growth itself, and in the 
posterior by the stretching of the anterior wall. In each the 
growth was incarcerated in the pelvis, and, as might be 


expected, gave rise to well-marked pressure symptoms, particu- 
larly associated with micturition. 

The entire cervix was involved in twelve instances. In 
eight the growth developed in the posterior wall, in four the 
anterior wall. In these cases, through the stretching and 
thinning of the uninvolved cervical lip, the os externum was 
much dilated, and easily admitted the tip of the finger. 

All were sufficiently large to fill the true pelvis, and thus 
conformed to the typical ovoid shape, as in the previous 

The disposition of the peritoneum is of interest, as it 
naturally is varied according to the position of the tumour in 
the anterior or posterior wall. When anterior, the retro- 
uterine pouch is in no way interfered with, and the peritoneum 
extends downwards over the upper third of the posterior 
vaginal wall; while in the posterior tumours the peritoneum 
is lifted up over the top of the growth, and thus separated 
from its usual relations to the vaginal roof. In the latter 
instances the tumour occupied the recto-vaginal septum, and 
was in close apposition to the rectum and vagina, a relation of 
very considerable importance with regard to operative removal 
(Fig. 3). When anteriorly situated, the peritoneum along with 
the bladder is lifted high in the abdomen, and separated from 
the anterior abdominal wall for a considerable distance. 

In all of the cases but one the growths were uninodular, 
although in eight instances they were associated with fibro- 
matous nodules in the uterine body. In the multinodular 
growth which grew from the anterior wall, and involved the 
entire cervix, the displacement of the surrounding organs was 
extreme. The bladder was drawn round to the right side of 
the pelvis, while the fundus uteri was displaced into the retro- 
uterine pouch. The entire brim of the pelvis was filled by 
the tumour, and the usual landmarks were thus completely 
obliterated (Fig. 4). 



Clinical Features. — As might be expected from the situation 
and size of the tumours, intrapelvic pressure symptoms were 
mainly in evidence. These in the majority of instances were 
associated with the functions of the bladder, mainly in the 
direction of retention of urine. Firstly, this was complained of 
at or about the menstrual period, when the tumour was tem- 
porarily engorged, but later it occurred at other times ; and in 

Fig. 3.— Unencapsulated cervical fibroid of posterior wall involving entire cervix. Dotted 
line shows peritoneum and obliteration of retro-uterine pouch. 

one instance it was permanently present; here the irregular 
pressure on the base of the bladder continued to make cathe- 
terisation difficult, as from the prolonged distension of the 
bladder it remained atonic and pouched, so that unless the 
catheter actually passed into the upper diverticulum only 
partial evacuation was procured. Pain, as the result of 
pressure on the pelvic nerves, is, strangely enough, not a 



marked symptom ; it is by no means so evident as in incar- 
cerated fibroids of the body. Haemorrhage was a most unequal 
symptom, and in only ten of the twenty-two cases could be 
considered severe; seven of these being instances where the 
entire cervix was involved. In eight there was neither 
monorrhagia or metrorrhagia. 

It is probable in some instances the haemorrhage was 
increased by some attempt at the expulsion of the tumour 

Fro. 4.— Fibro-myoma involving the entire cervix. Small nodule in uterine body. 

below the mucosa. In this type not only is there a special 
disposition towards haemorrhage, but also a tendency to slough- 
ing and gangrene, probably due to some impairment in the 
blood supply. Haemorrhage must not, therefore, be considered 
a constant symptom, although frequently present. 

In my own experience, in only two instances did the 
tumour show any signs of degeneration. These were oedematous 


and gangrenous. In a case, however, of Professor Simpson's, in 
which I had the honour of assisting him in its removal, a large 
central degeneration cyst was present, similar to those met 
with in the so-called fibro-cystic myomata of the uterine body ; 
the contents were spontaneously coagulable on evacuation. 

Operation. — The operation for the removal of these growths, 
though by no means simple, does not present the formidable 
difficulties which from their situation one would anticipate, as 
they are usually readily enucleated from their surroundings. 
Perhaps the most troublesome difficulties are the absence of the 
usual landmarks from the displacement of the surrounding 
structures, the close relation to the ureters, and the inability to 
recognise the elongated and stretched uterine arteries. In one 
case, where the tumour arose from the anterior lip and filled 
the brim of the pelvis, incarcerating the retroverted fundus with 
the ovaries in the pouch of Douglas, and pushing the distended 
bladder far round to the right side, when the abdomen was 
opened nothing but a large indefinite mass could be seen, which 
required to be enucleated from its subperitoneal bed before the 
true relation of parts could be made out (Fig. 4). 

As might be expected, the incision in the vaginal wall is 
preferably to be commenced anteriorly after stripping the 
bladder down. In a typical case, the following may be described 
as the method of operating. On opening the abdomen, the 
small uterine body will be seen situated on the top of the 
growth. This is laid hold of by a pair of strong vulsella and 
forcibly pulled upwards. The infundibulo pelvic ligaments are 
tied and the broad ligament cut. The round ligaments are 
similarly dealt with. In anterior growths, the loose peri- 
toneum covering the tumour is then incised from pelvic wall 
to pelvic wall anteriorly, and, with the bladder, is freed from 
the mass ; this is usually easily accomplished, but care must 
be taken not to tear through the large plexus of vesical 
veins, which may cause most troublesome haemorrhage. The 

BY DR F. W. N. HAULTA1N. 129 

uterine arteries are now ligatured as low as possible and 

An opening is then made into the anterior vaginal fornix. 
This is enlarged laterally, extending round the tumour mass, 
the vaginal wall being gripped in small sections by forceps 
before cutting. By this means, bleeding from the vaginal 
arteries, wherever present, is controlled, and they can be easily 
detected and tied. 

When the growth is from the posterior wall, the loose 
peritoneum covering is incised in like manner and the tumour 
enucleated from the rectum and its bed, care being taken to 
keep close to the tumour laterally to avoid the ureters. After 
enucleation, the anterior vaginal vault is opened and the tumour 
removed by a process similar to that in the anterior growth. 
After all vessels have been tied, the bed of the tumour is 
packed with gauze and the end drawn down into the vagina. 
The two layers of the peritoneum are now stitched completely 
over the gauze by continuous thin suture in Lembert fashion. 
The gauze is withdrawn after forty-eight hours, by which time 
all oozing has been controlled. The vagina is then gently 
syringed out daily with warm sterilised water. In supravaginal 
growths, after enucleation the remaining portion of the cervix 
is cut across and treated by the subtotal method. 

In posterior growths, the close connection of the tumour to 
the rectum from which it has practically been stripped, forms a 
distinct source f of danger, in so far as the bed of the tumour 
may subsequently become infected by the Bacillus coli directly 
from the bowel. In three of my cases this complication 
occurred, and in two of these it proved fatal. It is well, there- 
fore, in these instances to see that the bowel is not only freely 
evacuated but cleansed by means of weak antiseptic enemata. 

In cases where there is a distinct muscular capsule to the 
growth, it is undoubtedly safer to incise it transversely from 
side to side at the same level as the peritoneal incision, and 



proceed to enucleate the tumour' from the capsule. The cavity 
which remains is then packed with gauze and the end drawn 
through the vagina; by this means there is no baring of the 
rectum, and the risks of infection from this source minimised 
(Fig. 5). 

Fig. 5.— Uterus and posterior cervical fibro-myoma removed, the latter enucleated 
from its capsule. 

In these cases the tumour may be enucleated after vertically 
splitting the uterine body and thus reaching &ie bed of the 
tumour from above. This is the method adopted by Bland- 
Sutton and Eutherforcl Morison. A distinct capsule, however, 
is not always present, and complete removal is essential. 

The combination of large corporeal and cervical fibro- 
myomata is, fortunately, rare, and the difficulty and danger of 
their removal is very great. Personally, I know of no operation 
in gynaecology which offers so great difficulties, from the want 
of definite landmarks and the distortion of surrounding im- 


portant organs. Each case seems more puzzling than the other. 
The dislocation of the bladder and ureters, the splitting of the 
layers of the mesosigmoid, and the want of room to work from 
the incarceration in the true pelvis, all tend to prevent con- 
ventional method of action and demand originality. 

Perhaps the most interesting of these it has been my fortune 
to meet was the removal of the specimen I show of combined 
fibroid and pregnancy five months, in which labour was present. 

I have, unfortunately, to record three deaths in the thirty 
cases operated upon, a mortality of 10 per cent., which un- 
doubtedly compares most unfavourably with my experience of 
hysterectomy for corporeal fibroids, which shows a mortality of 
slightly more than 1 per cent. 

That the operation is legitimate, however, even with such 
results, there can be no gainsaying, as the symptoms present in 
all cases were severe and dangerous, and doubtless would 
shortly have caused the death of the individual, a very different 
status from the victims of corporeal fibroids, in whom the 
operation is undertaken for discomfort and semi-invalidism, and 
the life of the patient is only threatened in a comparatively few 

Two of the deaths occurred in posterior cases, and were due 
to septic infection; this was probably predisposed to by the 
large area of enucleation, which involved baring the rectum. 
In these cases, therefore, I now always, if possibly, enucleate 
from their capsule, so that stripping from the rectum may be 
avoided. The third death was also due to septic infection from 
a sloughing cervical tumour associated with a large corporeal 

The President said they had listened with the greatest 
interest and pleasure to Dr Haultain's paper. It was only 
after seeing a great number of cases that one was able to 


make out the small points of difference that existed, more 
especially with regard to the relationship of parts to other 
organs, and the relation of the tumour to the uterus itself. 
Dr Haultain's communication had greatly cleared up the 
topography of these cervical fibroids, and would enable them in 
the future to classify them into anterior and posterior 
varieties, and according to the three segments of which the 
cervix is composed. The deductions from such topographical 
knowledge were very interesting with regard to treatment, and 
to the close proximity of the rectum. He had wondered 
when Dr Haultain was describing his cases, whether there had in 
any case been any infection of the tumour itself from the 
rectum. His own personal operative interference with cervical 
fibroids was limited to two cases : one which he had enucleated 
from the cervix, and in which he had had to face tremendous 
haemorrhage at the time ; and the second, in which he had done 
a pan -hysterectomy. Both cases had made a good recovery. 
In both of them the tumour had affected the intravaginal 
portion, and had been anterior also in both cases. Certainly, 
he thought that Dr Haultain's paper showed that with very 
few exceptions it was a very risky thing to approach these 
growths through the vagina, and that abdominal hysterectomy 
was the right thing to do. He was sure the Society was much 
indebted to Dr Haultain for bringing the cases forward in such 
a masterly way. 

Dr Barbour said that the President had touched on most of 
the points he had intended to refer to. He congratulated Dr 
Haultain on the clear and lucid description of these tumours in 
respect to the parts of the cervix from which they grew, and 
with regard to the displacement of the peritoneum. It was a 
very interesting fact that tumours growing from the cervix 
posteriorly lifted the peritoneum up, and that the pouch of 
Douglas was displaced to such a height. Dr Haultain had 
drawn attention to the interesting fact that usually the fibroid 

BY Dli F. W. N. HAULTAIN. 133 

tumours of the cervix were single — that is to say, that one did 
not often see a fibroid of the cervix and several of the uterus ; 
and, indeed, that one might almost assume that a cervical 
fibroid will be a single tumour, although now and again there 
were exceptions. For that reason he wondered whether one of 
the tumours figured was a cervical fibroid. It seemed to 
extend a good way up into the anterior uterine segment, and 
to be as much a uterine as a cervical tumour. He wished to 
ask if there was any liability to kidney complications in any of 
the cases ; and to Dr Haultain's reply in the negative, he said 
it was interesting that although there must be considerable 
pressure on the ureters, yet there was no disturbance from the 
kidneys. Dr Haultain had brought out an interesting and 
important point with regard to the operation — in regard to 
leaving the capsule in the case of any tumour that comes to be 
in relation to the rectum. In olden days the operation of 
enucleation was a dangerous one for the patient, and to have 
left a portion of the capsule behind, would have been con- 
sidered to have increased the risk of the operation. But it was 
now evident that if the tumour was thoroughly cleaned out, it 
was quite safe to pack with gauze, and that with good drainage 
from below, the risk of infection was less. He looked on the 
paper as a very important contribution, not only to the topo- 
graphy of the tumours, but also as to the operative treatment, 
and was in a line with the splendid work Dr Haultain had 
already done on the subject. 

Dr Brewis said that he had listened with the greatest 
pleasure and with considerable profit to the very valuable paper 
of Dr Haultain. Dr Haultain had treated the subject so fully 
and dealt with it in so admirable a manner, that there was very 
little left to say. His experience of this class of case accorded 
entirely with that of Dr Haultain, with one exception. He 
had thought he had met with all possible varieties of 
cervical fibroids, but he found he had not mot with two of the 


examples that Dr Haultain had figured. He said there was 
really nothing to criticise, though he would state his experience. 
As to the frequency of cervical fibroids, his experiences coin- 
cided with that of Dr Haultain. In 10 per cent, of the 
cases requiring abdominal section he had found cervical fibroids. 
Dr Haultain had classified the tumours into the usual divisions 
of the cervix. He thought they might also be designated as 
submucous, interstitial, and subserous. With regard to 
symptoms, every cervical fibroid was more or less intrapelvic, 
and when growing big enough gave rise to pressure symptoms. 
The outstanding, and frequently the only symptom, was reten- 
tion of urine. He was accustomed to tell his students that if 
a non-pregnant patient above a certain age came complaining of 
retention of urine, almost certainly she had a fibroid tumour, 
and in nine cases out of ten it would be a cervical fibroid. He 
had also met with haemorrhage in some of his cases, and in such 
the tumour had usually been of the submucous variety. As to 
the treatment of these tumours, the various anatomical features 
they presented required different technique. They had to 
avoid the bladder in front, the rectum behind, and the ureters 
at the side. He had had several cases of cervical fibroid that 
had been limited entirely to the supravaginal portion of the 
cervix, and each case had been done by the supravaginal opera- 
tion. In one case the tumour had grown backwards, and 
opened up the meso-rectum, and was very difficult to remove. 
He had had a number of cases similar to the ones represented 
— subserous cervical fibroids growing either from the anterior 
or posterior aspect. In these cases, after having opened the 
abdomen and divided the peritoneum, he had shelled the 
tumour out of its capsule, put stitches into the bed of the 
tumour, and drained per vaginam, closing the abdomen without 
removing the uterus. He had done this in subserous tumours, 
growing both from the anterior and posterior aspect of the 
cervix. Submucous or interstitial differed quite from that 


variety. They formed a more or less elliptical tumour. If 
large, they filled up the whole pelvis, and were very difficult to 
remove; because, as Dr Haultain pointed out, the uterine 
vessels were spread out alongside, elongated, and difficult to 
ligature. From want of room it was also difficult to avoid the 
ureters. He had removed at least six of such cases by pan- 
hysterectomy, much as described by Dr Haultain. In a 
number of cases he had found that this operation was simpli- 
fied by splitting the uterus; after having divided the broad 
ligaments as far down as possible, and pushed down the bladder, 
he had split the uterus down vertically from the fundus, and 
enucleated the tumour. Enucleation might be difficult, and 
not safe to practise. In such a case, even without enucleation, 
the splitting of the uterus and tumour was of the greatest 
service, because one can pull up one half and ligature the 
vessels, and then do the same on the other side ; it was then a 
simple matter afterwards to open the vagina. Enucleation was 
of the greatest benefit, not only in cervical fibroids, but also in 
corporeal fibroids. In the most difficult cases, where some- 
times one did not know where one was, one could incise and 
get a blunt instrument between the capsule and the tumour 
and shell it out, and might shell out several in that way. 
After that was done, that which had been very complicated 
became quite simple. He cited one remarkable case in which 
the patient had come to him after the eighteenth operation. 
He was told that each time she had presented herself previously 
to her doctor, there was a fibroid at the vagina, and that several 
inches of it were removed. When the patient came under his 
care for the nineteenth operation, he had removed the whole 
uterus. Dr Haul tain's paper was one of the greatest value, 
and perfect in all its details, not lending itself to any criticism. 



By A. H. F. Barbour, M.D., University Lecturer on Gyniecoloiry. 

The interesting paper by Dr Brewis on two cases of pregnancy, 
complicated by fibroid tumours, treated by hysterectomy, read 
at the December Meeting of our Society, induces me to place on 
record two cases of operation for similar conditions, performed 
during the last few months. These cases differ from those 
recorded by Dr Brewis in that the operation was done at an 
earlier period, when it was not a question of Cesarean section. 
Under the rarity of the condition I may mention that these 
are the first cases that have come under my notice in connection 
with my experience at the Eoyal Infirmary, which extends now 
over many years. The clinical histories of these cases are as 
follows : — 

Case I. Fibroid Tumour of Cervix. — After five normal 
pregnancies and labours patient became pregnant, and had 
repeated haemorrhages during pregnancy, followed by a natural 
labour at term. Eighteen months later an abortion at the sixth 
month, the haemorrhage during the pregnancy preventing her 
knowing her condition until abortion occurred. A year later, 
after four months' amenorrhoea, a tumour the size of a foetal 
head discovered in the pelvis, growing from the posterior lip of 
the cervix and displacing the uterus upwards. Pan -hysterec- 
tomy a fortnight later. Eecovery. 

Case II. Fibroid Tumour of Posterior Wall of Uterus. — An 
abortion at the third month, a year after marriage. Eight 
months later became pregnant again ; and now, after four and a 
half months' amenorrhoea, has a uterine fibroid about 4 inches 
in diameter to the right, displacing pregnant uterus to the left. 

DY DR A. H. F. BARBOUR. 137 

The tumour has a broad base of attachment, and has rotated 
the uterus, so that the right appendages lie anterior. As 
patient desired immediate operation, supravaginal hysterectomy 
was done. Eecovery. 

A comparative study of the cases raises the following 
interesting questions. 

As regards the situation of the tumour and the consequent 
displacement of the uterus, we note that the cervical fibroid 
measures 4J inches transversely, 2| vertically, and 3 antero- 
posteriorly. It springs from the posterior half of the cervix, 
its attachment extending up into the lower uterine segment. 
It is a single tumour, there being no other in the uterine wall. 
It must have been present for some time, as fibroid tumours of 
the cervix do not grow rapidly ; indeed we have evidence of its 
presence as far back as 1903, when the patient had her sixth 
child. The repeated haemorrhages in pregnancy in a patient 
who had had five previous normal pregnancies point to the 
development of this tumour, although it was not of sufficient 
size to interfere with her sixth labour. Her seventh pregnancy 
was also marked by haemorrhages, so frequent that the patient 
was unaware of her condition until a sixth month's foetus was 
expelled prematurely. 

It is an interesting fact that conception occurred with a 
tumour which, making allowance for its more rapid growth 
during the early months of pregnancy, must have been of 
considerable size. This shows that the sterility characteristic 
of these tumours is not due to their bulk, but to associated 
changes in the uterine mucosa. 

Another interesting question is how far the patient was 
gone in pregnancy. She gave a history of four and a half 
months' amenorrhoea, and of having felt foetal movements for 
six weeks, that is from the third month onwards. The fundus 
stood about 1 inch above the umbilicus. At first I was inclined 


to think that she was only four and a half months pregnant, 
and to attribute her having felt foetal movements from the 
third month to the fact that the tumour in the pelvis, displacing 
the uterus upwards, had brought it into contact with the 
abdominal wall at an earlier period than is usually the case. 
From the size of the uterus, however, and especially the length 
of the foetus, which measures 13 inches, it is evident that the 
pregnancy is of five and a half months' duration. In this case, 
what she described as her last menstruation must have been 
a haemorrhage some weeks after conception. 

The second case shows a fibroid tumour of the posterior 
wall of the uterus, measuring about 4 inches in diameter, and 
with a broad base of attachment extending from the level of 
the Fallopian tubes to the lower uterine segment. Before 
operation it looked is if we had to do with a tumour attached 
fco the right side of the uterus, displacing the pregnant uterus 
to the left ; on abdominal section, however, it was found that 
the tumour had caused rotation of the uterus, so that the right 
uterine appendages were opposite the abdominal incision. 
From the size and position of the tumour, delivery of a child, 
in the event of pregnancy going on until the child was viable, 
could only have been possible by Csesarean section. 

These cases also raise the interesting question of the reasons 
for operative interference, and whether immediate operation was 
necessary. In the case of the cervical fibroid the appearance 
of the part of the tumour presenting at the vulva decided the 
question. The tumour was undergoing infection, and though 
there was no temperature it was evident that it would not be 
safe to allow pregnancy to go on in the hope of getting a living 
child. Even had the tumour not been undergoing necrotic 
changes it would have been a doubtful policy to temporise, 
because labour had come on prematurely in the previous 
pregnancy ; and to defer operation until labour was advanced 
would have greatly increased the risk to the patient. The 

BY DR A. H. F. BARBOUR. 139 

dilatation of the cervix seen in the preparation shows that as a 
matter of fact labour had already begun, though no pains had 
been noticed, before the patient was on the operating table. 

The necessity for immediate operation was not so obvious 
in the second case. Although it is doubtful whether pregnancy 
would have gone on until a viable child could have been 
obtained by Cesarean section, yet, had there been an opportunity 
for keeping the patient under observation, the operation might 
have been deferred. In forming an opinion in a case of this 
nature one has to be guided by the patient's wishes, and had 
she been anxious to run a certain amount of risk for the 
possibility of having a living child, I should have advised delay. 
Both the patient, however, and her husband wished to have as 
little risk as possible, and requested immediate interference. 

With regard to the operation itself, little requires to be said. 
In the first case pan-hysterectomy was performed, care being 
taken to prevent infection of the peritoneal cavity as the 
tumour was lifted out of the pelvis. In the second case supra- 
vaginal hysterectomy was performed, the cervix being left. 
In both cases I was struck by the fact that the operation of 
hysterectomy is not made more difficult by the existence of 
pregnancy. While more ligatures are necessary to control 
venous haemorrhage, the stretching of the peritoneum and 
opening out of the ligaments, resulting from the pregnant 
condition, facilitates the dealing with bleeding points and the 
covering over of the pelvic floor with peritoneum. Both 
patients made an excellent recovery. 


Meeting V. — March 13, 1907. 

Dr J. W. Ballantyne, President, in the Chair. 

I. Dr Brewis showed — (a) a four months' fcetus (extra- 
uterine) removed by vaginal section, and A portion of the 
placenta. The patient was aged 35 ; had had five children, the 
youngest of whom was five years old ; the last period was on 
21st October, the operation on 22nd February. The primary 
rupture took place on the eighth week, as far as could be ascer- 
tained, for she had been seized at that time with severe pain in 
the lower abdomen, resembling the pains of labour ; the pains 
were not followed by any collapse. The vomiting and pain 
had continued till the time of operation. On examination the 
whole of the lower abdomen had been found to be distended 
with a tense swelling, not firm and resistant, but more like an 
ovarian cyst. Towards the symphysis, and in the left iliac 
region, there was distinct resistance and dullness on percussion. 
Per vaginam, the uterus was found to be enlarged and pushed 
to the front by a tense cystic swelling, filling up the posterior 
part of the pelvis. The diagnosis of tubal rupture of an extra- 
uterine gestation was made. He had operated from below, as 
was his custom in most of these cases. The patient was very 
feeble ; haemoglobin 50 per cent. ; and he had carried out venous 
transfusion while the patient was getting the anaesthetic. He 
had opened through the posterior fornix opening into the 
sac, from which had poured fluid which looked like liquor 
amnii. He got hold of a foot of the infant and delivered 
rapidly, and had taken away a piece of the placenta and 
blood-clot. The fcetus was living at birth; the cord was 
attached to the upper part of the sac ; in the left iliac region 
was the rest of the placenta, but he had not considered it wise 
to remove the placenta from that site. The sac was packed 
with gauze (16 yards were used). The rupture had been 
between the layers of the mesometrium, the embryo and 


membranes had escaped into the portion of the pelvis uninjured, 
and the pregnancy had continued. As the sac enlarged, it lifted 
up the peritoneum from the anterior surface of the rectum and 
the anterior abdominal wall, and the explanation of the vomit- 
ing was that the pregnancy had continued — it was the vomiting 
of pregnancy. He took it that the sac was in imminent 
danger of undergoing secondary rupture. He pointed out 
the advantage of operating from below;, for if this had been 
opened from the front he would have encountered the placenta 
first, and the patient would have succumbed to any operative 
procedure from above. But from below the operation had 
been easy and comparatively safe. The placenta had not yet 
come away, but was coming away in pieces, and the patient 
was doing quite well. 

(&) Large subperitoneal fibroid, showing mucoid degenera- 
tion, with a very small pedicle. 

(c) Cervical fibroid, growing from the anterior wall of the 
cervix, and removed by pan-hysterectomy. 

(d) Two dermoids removed from the same patient, who 
was married and had had a large family. 

(e) Double pyosalpinx, removed by the operation of 
hystero-salpingo-oophorectomy — it was a tuberculous case. 
The tube had ruptured at the time of operation, and pus 
escaped over the field of operation; but the patient had 
recovered without a bad symptom — the pus being sterile. 

(/) Ovarian tumour, from a patient who had been operated 
on by Thomas Keith, nineteen years before. It was a case in 
which Keith had evidently not thought it wise to remove the 
whole tumour, and had stitched the cyst-wall to the abdominal 
wound, leaving a portion of the tumour. When the case came 
under his care, the tumour had filled the greater part of the 
abdomen, and was attached to a large surface of the anterior 
abdominal wall. The tumour had been removed by taking away 
a great part of the anterior abdominal wall. 


IT. Dr Haig Ferguson showed — (a) A pelvic abdominal 
tumour from patient set. 38, diagnosed as uterine fibroid, 
producing severe oedema of right lower extremity from pressure 
upon right external iliac vein. This was practically the only 
symptom caused by the tumour, as the patient had no metror- 
rhagia, no severe menorrhagia, and only a copious watery 
intermenstrual discharge. The specimen showed — (1) large 
submucous fibroid ; (2) fibroid which was removed from 
between the layers of the right broad ligament, and which was 
continuous with the submucous fibroid. Apparently the 
tumour commenced interstitially, and grew simultaneously 
outwards between the layers of the broad ligament and in- 
wards as a submucous fibroid, the two portions being united by 
a narrow neck. Pressure symptoms were completely relieved 
by operation. 

(b) Pelvis of primipara, who was unconscious from acute 
eclamptic toxsemia at full time, with strong labour pains, and 
demanding rapid delivery. Head lay persistent occipito- 
posterior, and was not engaged at the brim. Forceps proved 
unavailing, and as child was dead, craniotomy was performed. 
Patient never regained consciousness. The measurements of the 
pelvis were : — Interspinous, 9 \ inches ; intercristal, 9 £ inches ; 
conjugata vera, 3 J inches; conjugata diagonalis, 3f inches; 
transverse (widest point), 5 J inches, (available), 4 J inches; 
left oblique, 4J inches; right oblique, 5 inches; cavity fairly 
roomy; transverse at outlet, 4J inches. Projecting into the 
lumen of the brim opposite the right iliac pectineal eminence 
was a spinous process, causing shortening of left oblique 
diameter by J inch, as compared with right. Type: — The pelvis 
was apparently a justo-minor, complicated with rickets. It 
seemed to be after the type described by Litzmann, in that it 
had an ungainly and angular appearance, and in the marked 
prominence of the pubic crests. There was a slight scoliosis. 
The head lay in the RO.P. position, the occiput becoming 


impacted on the abnormal spinous projection on the right ilio- 
pectineal line — a fact which could be easily made out during the 
conduct of the labour, and necessitating craniotomy. Un- 
fortunately, the birth of the foetus did not modify the toxaemic 
condition, the fits continuing, and the patient dying in toxsemic 


By Sir J. Halliday Croom, M.D., Professor of Midwifery in the 
University of Edinburgh. 

The relationship of exophthalmic goitre, known as Graves' 
disease or Basedow's disease, to pregnancy, parturition, and to 
various forms of gynaecological disease, has received compara- 
tively little attention in this country, and as I have observed a 
number of cases within recent years, I venture to record some 
conclusions I have arrived at, although I fear in the main they 
are negative. 

It is unnecessary to describe the symptoms characteristic of 
this disease, nor in a short paper can I deal with the theories as 
to its etiology. Suffice it that amongst many supposed causes 
brought forward by various authorities we find changes in the 
blood, changes in the heart muscle, enteroptosis, floating kidney, 
auto-intoxication from digestive disorders, impairment of the 
lymphatic circulation, changes in the ganglion cells of the cortex, 
changes in the medulla, lesions of the sympathetic, lesions of 
the restiform bodies, and finally hypersecretion of the thyroid 

This last point, the question of the thyroid, is an extremely 
difficult and important one. Eichardson, whose essay on the 
subject is classic, says that the spontaneous enlargement and 
hypersecretion of the gland is more than improbable; and 


Gibson, in his able and valuable paper on "Adaptation and 
Compensation," condemns non-functional hypertrophy in any 
part of the human organism in characteristic language as "a 
base figment of the imagination." 

As we shall see later, there seems to be a direct relationship 
between pregnancy and the thyroid, a point to which attention 
has been drawn recently by the researches of Nicholson and 
others into the connection between eclampsia and the thyroid 
gland. And if we consider the undoubtedly close connection 
between the thyroid and metabolism and assimilation, we must 
at least admit the plausibility of Thomson's claim that the causa 
causans is a toxaemia, and that this produces a perversion or an 
increase in the quantity of the thyroid secretion. It is certain 
that pathologically the changes which take place in the thyroid 
gland are usually a parenchymatous hyperplasia with changes 
in the colloid material and degenerative changes in the 
protoplasm and nuclei. There is, however, no definite 
histological change in the organ that can be called specific 
of exophthalmic goitre, and all the above changes may be found 
in patients who present none of the symptoms of Graves' 

The disease is, roughly speaking, ten times more common in 
women than in men. This I take to be an undisputed fact. 
But, judging from the statistics of my own hospital work, which 
has been entirely confined to the Maternity Hospital and the 
gynaecological wards of the Koyal Infirmary of Edinburgh, it 
would seem to be a comparatively rare condition associated 
either with pregnancy or uterine affections. At all events, 
looking back over my work in the Maternity Hospital, and 
going over the statistics of the hospital, which include 15,000 
cases, I have only met with one case in which there was any 
reference made to goitre, and in that case there were neither 
tremors nor exophthalmos. During the fifteen years in which I 
had charge of the gynaecological ward in the Eoyal Infirmary, I 


met with only two cases of exophthalmic goitre which were 
associated with uterine affections ; to these I shall refer later. 
I have occasionally seen cases of exophthalmic goitre in associa- 
tion with my colleagues in the ordinary medical wards of the 
Royal Infirmary, but in these cases, except irregular menstrua- 
tion, there was no affection of the genital organs whatever. 

It must therefore be apparent that the disease must be more 
common in the better classes than amongst those who attend 
hospitals; and from all that is known of its etiology, this is 
just what one would expect of a disease arising, as it does very 
often, after shock and mental anxiety in highly strung nervous 

When regard is had to the age at which exophthalmic goitre 
is most prevalent, we find that it coincides with the active 
period of uterine life. Taking a table from Murray's most 
interesting paper, I find that the youngest case was 15 years old 
and the oldest 65. The most common period lay between 16 and 
35, but quite a number occurred between the ages of 40 and 50, 
a period coinciding with the normal changes which take place 
in the genital system at the menopause. 

That there is a relationship between the generative apparatus 
and the thyroid, there can be no question. My experience 
entirely coincides with that of Martin, whose extremely able 
and interesting paper has just been published, that a great many 
girls suffering from exophthalmic goitre have special discomfort 
during menstruation, and I have noticed that the thyroid gland 
enlarges in some cases at the same time. It is not necessary, 
nor in my experience is it common, to have pathological con- 
ditions of the pelvic viscera associated with exophthalmic goitre. 
It seems to me that the periods when exophthalmic goitre is 
most likely to be developed or exaggerated, are the three epochs 
when the generative system is at the height of its activity, — at 
puberty, at menstruation, and during pregnancy. May I quote 
a sentence from Martin's excellent work: "Growth is more 



active than ever at the age of puberty, and with the onset of 
activity of the generative organs the vitality of all parts of the 
organism is raised, and the glands involved in the metabolism 
are put to an unprecedented strain; especially is this so in 
the female sex." 

The question of the condition of the thyroid during preg- 
nancy has received a very considerable amount of attention. 
That there is a greater or less increase of its volume during 
pregnancy seems to me to be beyond dispute, and that it 
gradually disappears after delivery is an ascertained fact. 
Freund it was who first systematically examined the relations 
between the thyroid gland and the female genitals. He arrived 
at the conclusion that the relation occurs not through the 
nervous system but through the blood. Heidenreich was of 
opinion that the pregnant uterus hindered respiration, and 
thus led to an accumulation of blood in the gland. The general 
opinion, however, seemed to be that the enlargement was 
sympathetic. Such was the way the question stood when 
Lange approached the subject, and in a very interesting and 
original paper discussed the matter, taking his statistics from 
observations made by himself from October 1893 to January 
1898. The result of his examinations very much corroborated 
those of Freund, and he found that a hyperplasia of the 
thyroid was an almost constant concomitant of pregnancy. Lange 
made his observations most carefully, eliminating all apparently 
obvious causes leading to mistake. It is, for instance, the 
tendency of many pregnant women to put on fat, and therefore 
he only took women with thin necks, so as to make no possible 
error ; and, furthermore, in measuring the neck after accouche- 
ment, especially after tedious labour, he only did so after 
twenty-four hours, as the neck is apt to be turgid and swollen 
immediately after labour. 

The important conclusion he arrived at was that hyperplasia 
of the thyroid is a physiological appearance in pregnancy, and 


that in the majority of cases it begins about the sixth month, 
and ceases at an indefinite period after labour. He points out 
that with kidney affections peculiar to pregnant women there 
is no hyperplasia, and in an able paper by Nicholson, this 
matter is very fully discussed. Upon this matter I have no 
intention of entering to-night. 

Considering, therefore, the frequency with which this 
disease occurs ; considering, further, the fact that it occurs in 
women during the active period of menstrual life; consider- 
ing, further, the intimate connection which apparently exists 
between the thyroid gland and menstruation and pregnancy — 
one would naturally expect to have exophthalmic goitre more 
commonly associated with uterine conditions than seems to be 
the case. 

Kleinwachter, in his work published in 1890, paid particular 
attention to the relationship between the sexual organs and this 
disorder, pointing out that in many cases the sexual develop- 
ment was wanting. In the case which he particularly described, 
there was a loss of the hair ; the mammary glands were atrophied, 
almost completely so; the mons veneris was poor in adipose 
tissue and destitute of hair ; the labia were flabby, especially 
the minora ; the vulva was gaping ; the whole vagina was loose, 
with slight prolapse of the anterior vaginal wall; the portio 
vaginalis was scarcely the size of a kidney bean; the uterus 
was sunk down, the cavity was small, with the walls very thin 
and flabby; both ovaries were small and tender. These 
changes, in fact, entirely correspond with senile marasmus. 
Similar changes in the sexual sphere were noted by Mobius and 

Cholmogoroff records a case as follows : — A woman, ret. 32. 
Eight previous full-term labours, last in November 1892. Well 
built ; moderate development of subcutaneous fat ; no exopthal- 
mos ; slight tremor of the hands ; frequent and severe attacks 
of palpitation, which had existed before marriage, and had 


been explained by the doctor as due to anaemia. There was 
considerable increase of the thyroid gland. This increase in 
the thyroid was noticed in the fourth pregnancy. The gland 
gradually grew larger with each pregnancy. Patient's mother, 
set. 60, had a large goitre, and a sister a smaller one. In the 
mother and sister there were no symptoms of Graves' disease. 

The patient came under Cholmogoroff's care owing to a 
bleeding of three weeks in connection with an incomplete 
abortion. The breasts atrophied in spite of the pregnancy; 
before this the breasts had been well developed. In the end of 
1893, there occurred a tenth pregnancy, resulting in abortion. 
The symptoms became worse in each succeeding pregnancy. 

Jouin refers to a connection between the menopause and 
Graves' disease. He observed in forty-three cases that the 
uterine lesion preceded the Graves' disease. Improvement in 
the local condition, he avers, is always accompanied by improve- 
ment of the general condition. 

Doleris, on the other hand, believes that the treatment of 
the uterine disease might cure women having tachycardia 
simulating Graves' disease, but in the case of those having true 
exophthalmic goitre it would be imprudent to promise to cure 
them of their goitre by treatment directed against their uterine 

In those cases that have come under my own observation, 
I have only met with abnormality in the sexual organs in three 

Case I.— Sent to me by Dr Haggart of Aberfeldy. The 
patient had well-marked exophthalmic goitre. She was sent to 
my care specially because she was suffering from profuse 
menstruation and recurrent attacks of retention of urine. 

On examination, a fibroid tumour was found blocking up 
the pelvis. On placing the patient under an anaesthetic, she 
expired at once, before she had been touched with a view to 


operation. This case is particularly interesting to me, as it is 
the only case that I ever lost under the administration of an 
anaesthetic. Unfortunately, no post-mortem was permitted. 

Dr Luke, the anaesthetist to the Eoyal Infirmary, informs me 
that exophthalmic goitre is one of the most trying cases with 
which an anaesthetist has to deal. They are in many ways 
worse than a simple goitre or Derbyshire neck, as, owing to the 
extreme nervousness of the patient and the great vascular 
excitement, the conditions favouring sudden cardiac failure are 
present in a marked degree, and conditions are not improved by 
the possible, and indeed probable, narrowing of the air- way by 
the thyroid growth. Such cases he would place, as far as risk 
is concerned, alongside of aortic aneurysm, and bad cases of 
mitral stenosis and tricuspid regurgitation. 

Case II. — A single lady, aet. 50, with extremely marked 
exophthalmic goitre, with profuse haemorrhage almost con- 
tinuous. She had a large ovarian tumour on tha right side, 
and a polypus projecting from the cervix. She had been 
practically bedridden for two years, as much owing to the 
Graves' disease as to the haemorrhage. 

I first of all removed the polypus, and sometime afterwards 
performed ovariotomy. She made the usual recovery, and at 
the end of a month left the Home. It is interesting here to 
observe the fact that six months afterwards the goitre had very 
considerably diminished, and the exophthalmos, tremor, and 
tachycardia were very much better. At the end of three years, 
although still an invalid, and unable to support herself by her 
own exertions entirely, the symptoms were very much 

Case III. — One of the most interesting cases I have met 
with, was that of a girl with well-marked exophthalmic goitre, 


who had reached 20 years of age and had not menstruated. 
It was for the local condition she was brought to me. On 
examination, I found that the amenorrhea was due to an 
imperforate condition of the hymen, which was bulging, and 
there was a distinct tumour on the right side suprapubically. 
She had had regularly for years back the usual monthly dis- 
comfort, but no haemorrhage at all. I treated the case in the 
usual way, and she made an excellent recovery. There was no 
marked change in the condition of the exophthalmic goitre. 
I saw her ten years after that, and she still suffered from 
invalidism, due to her tremors and tachycardia. 

I have no record of any special abnormality in the sexual 
organs of those cases where the disease occurred in young 
single women, except that, in the majority of cases, the tendency 
was rather to menorrhagia than to amenorrhea. In one only, 
after the continuance of the disease for some years, amenorrhea 
became developed. But as the girl's emaciation was extreme, 
and no obvious benefit was to be got from local examinations, 
none was accordingly made. 

On the other hand, I have seen two girls in whom the 
disease developed just after puberty. Neither girl menstruated 
until she was about 20, and then only scantily. Both married, 
and were sterile. On examination, I found an infantile 
condition of the pelvic organs. 

Kleinwachter refers to two cases in young women, in the 
first of which menstruation was retarded and scanty ; and in 
the second case the menstrual period lasted six weeks. 

Hoedemaker records the case of a young woman, set. 29, 
who had suffered from exophthalmic goitre for two years. In 
her he found changes similar to those that describe the 

Bamour also records a case in which the uterus was atro- 
phied, and the ovaries and tubes not palpable. 

On the other hand, in my experience I have found, as I 


have said, that menorrhagia is the symptom when the disease 
is early and progressive, and amenorrhoea only pronounced 
when the disease is far advanced, or when it occurs very 
early in puberty. 

With regard to the occurrence of the disease in older 
unmarried women, I have had occasion to examine ten such. 
In not one of these ten cases have I found anything abnormal, 
except irregular and, for the most part, profuse menstruation. 
I am driven to the conclusion, therefore, that in many cases 
recorded, the atrophy of these organs was due more to the 
psychic effect than to any result of the actual disease, mental 
shock being, as I have already said, a very frequent cause of 
this condition. Nothing is more common than to find that the 
menstrual function is disturbed by psychic and mental con- 
ditions, and to these I attribute the amenorrhoea rather than to 
the existence of the disease itself. 

Furthermore, it must be kept in view that in a large number 
of the cases recorded the amenorrhoea and atrophy were the 
consequences not of the disease itself, but of its exhausting 
influences and long duration. 

Out of fifteen cases occurring in women under 30 years of 
age, which have been under my own observation, or have been 
seen with others, where a local examination was made, no 
apparent lesion of the pelvic organs could be discovered. An 
interesting point is that there was no record of any dysmenor- 
rhea, and that the condition of the flow was rather increased 
than otherwise. 

So far as the histories of my cases are concerned, the onset 
in every one had followed more or less nervous shock. One 
specially interesting case was that of a girl, set. 26, who, in 
addition to well-marked Graves' disease, had profuse menstrual 
discharge, and at the same time had monthly attacks of mania 
coincident with her menstruation, so bad that on several 
occasions she had to be confined in the padded ward in hospital. 


In this case, after consultation with my colleagues, I removed 
her ovaries, with a view first of all of controlling the haemor- 
rhage, and secondly, in the hope that the removal of the ovaries 
might also have the desired effect upon the mania. I heard 
from her regularly for two years after the operation, and she 
remained free of the maniacal attacks during that time, but her 
condition of exophthalmic goitre remained unchanged, although 
the menopause had been completely established. 

Sanger reports three cases of women he examined with this 
disease. In one case there was amenorrhoea, which Sanger 
explains as lactation amenorrhoea. The uterus was not atro- 

In the second case the menses were somewhat scanty, but 
this Sanger attributes to the approaching climacteric and the 
marked adiposity of the patient. In this case also the uterus 
was not atrophied. 

In the third case the woman was pregnant. 
In these three cases, therefore, Kleinwachter's contention 
that this disease is associated with atrophy is not borne out. 
On the other hand, some, like Caracoussi, have described several 
cases where there has been atrophy of the mammae. 

Therefore, from my own experience, as well as from the 
records of the cases that have been reported, especially abroad, 
I must arrive at the conclusion that there is no interdependence 
between pelvic disease and Graves' disease, because the same 
conditions, such as fright, or mental shock, which would 
precipitate Graves' disease, would at the same time affect the 
pelvic organs as well. 

With regard to the effect which pregnancy has on exoph- 
thalmic goitre and vice versd, as I have already pointed out, 
this disease is practically unknown in the Maternity Hospital 
in Edinburgh, and therefore the records of the cases which 
occurred under my charge are all from my private case book. 
I have myself observed twelve cases of exophthalmic goitre 


during pregnaucy, with the following results. In all of them 
the condition as to eyes, thyroid, and heart was very marked. 
It would extend this paper beyond due limits were I to record 
these cases in detail ; enough for me to say that in eight of the 
twelve the course of pregnancy was unaltered, and the delivery 
was uncomplicated, and, so far as I was able to judge, the 
affection in each of those eight cases was aggravated for a time 
after the labour was over. 

Of the four remaining cases, in Case L, the patient, set. 30, 
had post-partum haemorrhage, so profuse as to require the 
uterine cavity to be plugged. She recovered slowly from her 
haemorrhage, and afterwards suffered from superinvolution of 
the uterus. The labour took place eight years ago, and she has 
not menstruated since, and the uterus and ovaries remain small 
and atrophied. The exophthalmic goitre, though somewhat 
modified, is still sufficiently marked to make her an invalid. 
In this case I attribute the atrophy of the uterus and ovaries to 
the excessive haemorrhage. 

The second case was seen with the late Dr Duddingstone 
Wilson. A lady, set. 34, five months advanced in pregnancy of 
a third child. AVell-marked exophthalmos; the thyroid very 
considerably enlarged ; pulse 140 per minute ; marked tremors ; 
profuse perspiration. I was asked to see the case because of 
some haemorrhage; diagnosis, accidental haemorrhage; treat- 
ment, as the haemorrhage was slight, palliative. The symptoms 
of exophthalmic goitre had been present for six months before 
her present pregnancy, and had been induced, as she believed, 
by a fall from a dogcart. Previous to that accident, she had 
been in good health, rather robust ; since then she had become 
emaciated until the occurrence of the present pregnancy, when 
her symptoms became slightly aggravated, until during the past 
five months she had become very much emaciated, and been 
unable for her household duties. As the haemorrhage increased 
very markedly, it was determined to terminate the pregnancy, 


and this was done by dilating the cervix and turning. The 
placenta was found in its normal situation, the haemorrhage was 
comparatively slight, and the patient recovered very slowly 
from the immediate interference. 

In Case III., I was asked to see a patient, set. 29, pregnant 
of a first child three months, because of symptoms of miscarriage. 
When I saw her she had well-marked exophthalmic goitre, the 
exophthalmos being very pronounced, and the goitre but slight. 
The pulse was 130 per minute, and the tremors, though present, 
were not striking. The miscarriage, when I saw it, was inevit- 
able, the os being open and the ovum protruding. I therefore 
emptied the uterus, and although every precaution was taken, 
the haemorrhage was so profuse that she was reduced to pro- 
found anaemia, and remained in bed for three months. During 
this time, although the lines of treatment were mainly those of 
anaemia, and no special treatment was given for the exoph- 
thalmic goitre, yet in the course of the three months her 
symptoms of exophthalmic goitre very much diminished; the 
exophthalmos was less pronounced, and the pulse fell to under 
100. It is well worthy of notice that in this particular instance 
the result of the profuse haemorrhage was that the patient 
developed superinvolution, and that there was no menstruation 
again for twelve months afterwards. 

I saw Case IV. only after delivery was over, and that because 
of a severe convulsion three hours after delivery. The con- 
vulsions occurred at varying intervals, and with increased 
rapidity, until the patient died during an attack. She had had 
during the whole of her pregnancy and for a year before, well- 
marked exophthalmic goitre, with the usual group of symptoms 
of exophthalmos, goitre, tremqrs, and tachycardia. 

There is no lack of cases recorded showing that pregnancy 
considerably favours the formation of this disease. There are 
also many cases recorded by others which show that pregnancy 
often makes this disease considerably worse. Considering the 


high degree of susceptibility of the nervous system, and the 
well-marked hydrsemia and anaemia characteristic of pregnancy, 
results such as this are what one would expect. 

In a recent paper, Wilson of Birmingham records eight cases 
of exophthalmic goitre in pregnancy which had come under his 
notice. In only two did menstruation continue normal. In 
two there was monorrhagia, in four there was more or less 
amenorrhea, and in one of these there was premature atrophy 
of the sexual organs. 

Trousseau and Charcot taught that pregnancy had a favour- 
able influence on exophthalmic goitre, but they were unaware of 
the fact that the thyroid gland enlarges during pregnancy in 
the normal condition. Bucquet, again, on examination of 
twenty-one cases, arrived at the conclusion, first of all, that 
exophthalmic goitre can be provoked by pregnancy at a date 
more or less remote from confinement. The cases he quotes, 
however, are very uncertain, and his conclusions very indefinite. 
Further, he points out that when exophthalmic goitre occurs 
previous to pregnancy, the influence exerted by the pregnancy 
upon the goitre is very uncertain ; in his own words, it may be 
"either neutral, benign, or aggravated." He further quotes 
three cases, two of which seem accurate, that pregnancy may 
transform simple goitre into an exophthalmic goitre; and of 
the ten cases in which pregnancy occurred during exoph- 
thalmic goitre, one was unaltered, three were aggravated, and 
six were improved. He arrived at the conclusion, therefore, 
that amelioration of the symptoms is to be expected when 
pregnancy occurs in a woman suffering from exophthalmic 
goitre. But his conclusions must be taken with a certain 
amount of reservation, because at least seven of the cases which 
he quotes were complicated by typhoid fever. 

A more recent contribution to the subject is that of Audebert 
of Paris. He records a case in which the disease developed in 
the seventh month of pregnancy. There was a goitre and 


exophthalmos, as well as much anasarca and scanty urine. 
Delivery was followed by partial recovery, although the tremors 
and exophthalmos persisted. Audebert is inclined to look 
upon the disease in this case as a manifestation of the auto- 
intoxication of pregnancy. While a conclusion cannot be 
deduced from one case, the theory is interesting and suggestive, 
in view of our increasing knowledge of the complex relation- 
ships of the thyroid in pregnancy. 

To bring the whole matter to an issue, it seems to me that 
the conclusions to be arrived at are as follows : — 

First, that exophthalmic goitre is a comparatively frequent 
disorder of women. 

Secondly, that the thyroid is enlarged during pregnancy. 

Thirdly, that exophthalmic goitre and pregnancy are a very 
rare combination, as shown by the fact that out of 15,000 cases 
I have not met with one in hospital practice, and with only 
twelve in private and consulting practice. 

Fourthly, that the influence of pregnancy upon exoph- 
thalmic goitre is very uncertain, and that in the majority of 
cases it aggravates it. 

Fifthly, that the effect of exophthalmic goitre on pregnancy 
is practically nil ; and that, so far as my observations and those 
I have collated from other sources abroad go to prove, most 
pregnancies complicated with exophthalmic goitre follow a 
regular even course ; and that of the accidents that occur, the 
most frequent is haemorrhage, and occasionally abortion. 

Sixthly, that the relation between pelvic disease and exoph- 
thalmic goitre is rare, and that the effect of exophthalmic goitre 
on the reproductive system is in recent cases to cause irregular 
menstruation, mostly in the direction of monorrhagia, while in 
very advanced cases it may cause amenorrhoea. 

From these conclusions it must be apparent, therefore — 

1. That girls suffering from exophthalmic goitre need nut 
be precluded from marrying. 


2. That after marriage they need not be precluded from 

3. That if pregnancy occurs, there is no reason, except in 
advanced cases, to interrupt the pregnancy, even in spite of the 
fact that the children of women with exophthalmic goitre may 
be expected, according to some authorities, to develop neuro- 
pathic manifestations. 


Audebert. — Compt. rend. Soc. d'obst., de gynah et de pcediat. de 
Paris, July 1906. 

Bamour. — Centralbl.f. Gynah, Leipzig, 1891 

Begbie. — Mori. Journ. Med. Sc, 1843. 

Bucquet. — " Goitre exophthalmique et grossesse." Paris, 1895. 

Caracoussi. — "Dissertation." Berlin, 1889. 

Cheadle. — St George Hosp. Rep., 1878. 

Cholmogoroff. — Monatschr. f. Geburtsh. u. Gynah, Berlin, 
Bd. v. 

Dol^ris. — Nouv. arch, d'obst. et gynah, Paris, 1895. 

Freund. — Deutsche Ztschr.f. Chir., Leipzig, 1890. 

Gibson. — Trans. Med. Soc. London, 1904, vol. xxvii. 

Hodemaker. — Centralbl.f. Gynah, Leipzig, 1891. 

Jouin. — Nouv. arch, d'obst. et gyn., Paris, 1895. 

Kleinwachter. — Ztschr.f. Geburtsh. u. Gynah, Stuttgart, 1889; 
Centralbl.f. Gynah, Leipzig, 1890; Ibid., 1891; Ibid,, 1892. 

Lange. — Ztschr.f. Geburtsh. u. Gynah, Stuttgart, 1899. 

Laycock. — Med. Times and Gaz., London, 1864. 

Maude. — Practitioner, London, 1891. 

Murray. — "Diseases of the Thyroid Gland." London, 1896. 

Nicholson. — Edin. Med. Journ., August 1906. 

Kichardson. — "Thyroid and Parathyroid Glands." Phila- 
delphia, 1905. 

Theilhaber— Arch.f. Gynah, Berlin, 1895. 

Wilson.— Lancet, London, November 1906. 


The President said that the Society had heard with great 
interest the elaborate paper by Sir Halliday Croom. Although 
the results were somewhat negative at present, still the facts 
had been put before them in such a way that they knew what 
they were, and could draw conclusions from them. 

Br Barbour said the Fellows had to thank Sir Halliday very 
much for bringing before them an important subject which, he 
thought, did not lend itself very much to discussion. But the 
paper was an important contribution to the subject on account 
of its rarity. The importance of the condition had been 
brought before him in connection with the literature of frozen 
sections. In going into the cause of death in forty cases, one 
of them (which had given them one of the most important 
sections of the third stage) was from the sudden increase in the 
size of a goitre, which caused death from asphyxia, the post- 
mortem examination revealing that otherwise things were 
normal. This showed that the presence of goitre might be a 
serious condition in connection with the onset of labour, a 
point which Sir Halliday had not referred to in connection 
with his subject. It would be interesting to know whether 
any facts would come out during the discussion, with regard to 
its importance in connection with labour, for we would expect 
occasionally to hear of complications in connection with labour, 
even in the giving of the anaesthetic. Sir Halliday Croom's 
conclusions, although negative, were very important, because he 
thought that in the text-books it was stated that the presence 
of goitre was a rather serious condition, and should be a contra- 
indication to pregnancy. Edgar made as strong statements 
regarding goitre, as in connection with heart affections, stating 
that patients with Basedow's disease should not marry. It 
would be reassuring to be able to tell patients that goitre in 
pregnancy was not such a serious condition. As to the 
gynaecological aspect of the question, the results there seemed 
to be negative also. He thought Sir Halliday had shown 


that the occurrence of goitre with pelvic conditions must be 
looked upon as a coincidence. He had himself had two cases 
— (1) a patient with a fibroid tumour, who had been sent to him 
for operation ; but the patient had a goitre without exophthalmos, 
but of sufficient size to be a contra-indication to operation, and 
he had sent her to Professor Chiene, who had removed the 
goitre, and the patient had then returned to have the fibroid 
removed. (2) The second case was one who had come for 
a minor operation — the repair of the perineum. The condition 
not being an urgent one, he had thought it better not to 
operate. He thanked Sir Halliday for his very important 
clinical contribution to the Society. 

Br Brewis said he was sorry he was quite unable to discuss 
the paper. All he knew of exophthalmic goitre in relation to 
gynaecology and obstetrics, he had learnt that night. He had 
great pleasure in expressing his admiration for the very able 
and interesting paper that Sir Halliday Croom had given them. 
He could recollect two cases of exophthalmic goitre occurring in 
gynaecology. The patients were both young girls, and in both 
of them there was menorrhagia. In one case there was a large 
retroverted uterus to account for the menorrhagia, and in the 
other a small intra-uterine polypus. These were the only 
instances of exophthalmic goitre he remembered. He had 
operated several times on patients with large goitres — removing 
ovarian tumours and fibroid tumours, and had had no hesita- 
tion — his only concern was with regard to the anaesthetic. 
The conclusions Sir Halliday had drawn were of great value. 

Br Ritchie had listened with very much pleasure to Sir 
Halliday Croom's paper, and he was specially interested with 
his conclusions. In relation to marriage, goitre stands in a 
different position from Graves' disease. During pregnancy the 
former would certainly become worse ; in Graves' disease the 
result on the thyroid would be uncertain. Although Trousseau 
and Charcot had recommended marriage with the expectation 


that pregnancy would cure exophthalmic goitre, Trousseau had 
later a somewhat sad experience of the effect of pregnancy on 
that disease. Dr Kitchie was interested to note Sir Halliday's 
experience of post-partum haemorrhage in Graves' disease, 
because Lawson Tait's was similar. The etiology of exophthalmic 
goitre was not known, but Sir Halliday had made a very strong 
case for its being primarily nervous. 

Dr Oliphant Nicholson said he had listened with great 
interest to Sir Halliday Croom's paper. He had attended two 
cases of pregnancy complicated by typical Graves' disease 
during the last five years, both in multiparas, and both improved 
markedly afterwards. With a disease like exophthalmic 
goitre, which ran a very uncertain course, and which might end 
in spontaneous cure in two or more years, it was difficult to 
say at what stage of the disease pregnancy had supervened; 
whether in the stage of progression, or at the stage in which 
improvement was just setting in. In some cases the disease 
might be apparently cured after pregnancy, but it was difficult 
to say whether or not the cure was really due to the pregnancy. 
In one of his cases, in the later months of pregnancy, the 
tachycardia had improved very much, the size of the thyroid 
had diminished a great deal, and all the symptoms became less 
pronounced. In the puerperium things improved still more, 
and later on the symptoms passed entirely away. This patient 
had since been under the care of Dr Giles, and was regarded as 
completely cured. The whole question of the influence of 
pregnancy upon different diseases was a most interesting and 
important one; pregnancy, undoubtedly, exerted a beneficial 
influence on some diseases, and a baneful one on others. He 
was strongly of opinion that the explanation of the different 
effects produced was to be found in the manner in which the 
condition of pregnancy modified the thyroid activity. As 
regards labour in the cases mentioned, both were difficult. 
He had not then known the dangers of chloroform in such 


cases, and had given a large quantity, and the patient had not 
seemed any the worse for it. He wondered whether the 
danger of anaesthetics in these cases was a mechanical one from 
suffocation, owing to the size of the goitre, or whether there 
was in this disease any special tendency to heart-failure. He 
had had no special difficulty with regard to the breathing. In 
both cases there was considerable post-partum haemorrhage in 
the form of a steady oozing. This kind of haemorrhage was 
what one might expect in cases of Graves' disease, owing to the 
type of circulation present; characterised by a marked relaxa- 
tion of all the smaller blood-vessels. Sir Halliday Croom did 
not mention anything about the lactation in these cases; in 
both his cases there had been a very great secretion of milk. 
The connection between the thyroid gland and lactation was 
very obscure, indeed the whole subject of the thyroid in relation 
to pregnancy was so paradoxical, that at present one could draw 
no definite conclusions at all. When thyroid was given to 
nursing women it might increase the secretion of milk, and in 
cows Hertoghe had shown that it acted as a marked galactagogue. 
In myxcedema, even after the menopause was past, if one gave 
very large doses of thyroid, it happened sometimes, as Bramwell 
had recorded, that the breasts commenced to secrete milk 
abundantly. On the other hand, in animals the mammary 
gland sometimes secreted milk in large quantities after the 
thyroid gland had been removed. This happened in a bitch 
from which he (Dr Nicholson) had removed the entire thyroid 
gland a year previously. This animal was not pregnant, and 
yet the breasts became gorged with milk, and pups from 
another bitch were suckled on two different occasions. In the 
present state of our knowledge it was impossible to reconcile 
such contradictory observations. It was a good thing that Sir 
Halliday had brought up the subject of thyroid gland and 
pregnancy, because it was one that gained every year in im- 
portance, and seemed to have been much neglected in the past. 



Dr Church was glad he had had the pleasure and honour of 
hearing Sir Halliday's paper on this important subject. A few 
years ago, on analysing 1000 cases of his own, he had come 
across one case where exophthalmic goitre existed. It was in 
the case of a lady's last pregnancy, and twins were born. He 
thought the trend of the discussion had been to show that 
pregnancy instead of increasing and aggravating the condition 
seemed to be a curative agent. It was so in the case to which 
he referred. Though the symptoms had been most marked 
before pregnancy, she got almost entirely free of them after 
the twins were born. One child had died ; the other, now aged 
14 or 15 years, was subject to epilepsy, but that disease was 
in the family. In regard to this far-reaching subject he had 
thought it well to mention this case. 

Dr B. P. Watson wished to mention a case under his care 
of exophthalmic goitre associated with gynaecological disease. 
There was monorrhagia, dysmenorrhea, and pain in the back. 
There was marked exophthalmos, with a history of the patient 
having become very nervous of late years, subject to frequent 
sweatings, intermittent attacks of diarrhoea, and marked tremors. 
In every way it presented the characteristics of exophthalmic 
goitre. He had found that she had a large, tender, retroverted 
uterus, which was rather fixed at the time of examination. 
Under treatment the uterus had become smaller and movable, 
and was replaced, and a pessary inserted, and from that time 
onwards the symptoms of the exophthalmic goitre were less 
marked. This was eighteen months ago, and now there was 
only slight exophthalmos ; she was not nearly so nervous, and 
was very much improved. She had had one child five years 
ago, and no other since ; but whether the sterility was due to 
the exophthalmic goitre or to the position of the uterus, he 
could not say. 

Sir Halliday Groom, in reply, said he had really no reply to 
make. The only object of writing a paper was to record one's 


own personal experience so far as possible. And as he had had 
the fortune to have some hospital appointments for some years, 
he had thought it right to record the experience he had had. 
He did not think it would serve any good purpose for him to 
go over all the points suggested or spoken of that evening. He 
thought he had referred to them all pretty fully in his paper. 
He thanked the Society for the way it had received the paper. 

Meeting VI.— May 8, 1907. 
Dr J. W. Ballantyne, President, in the Chair. 

I. The following gentleman was elected an Ordinary Fellow 
of the Society:— A. M. Dick, M.B., Ch.B., Koyal Infirmary, 

II. Dr Haig Ferguson showed — (a) uterus with adeno- 
carcinoma of the body, removed from a woman, set. 42, 
married, and with two children ; the patient was also the subject 
of myxcedema. She had suffered from metrorrhagia for some 
time, and after being curetted, the report of the pathologist was 
that the condition was one of potential malignancy. He had, 
however, no doubt from the clinical condition, and removed the 
uterus per vaginam, because the patient was so very fat. He 
thought the ovaries were also malignant, but the report upon 
them was that there was a marked fibrosis, and no evidence 
of malignancy. The special interest of the case was that it 
was one of adeno-carcinoma in a muciparous woman. 

(b) Extra-uterine pregnancy, removed from a woman 
from whom four years ago he had removed the left Fallopian 
tube for pyosalpinx, leaving behind the left ovary, because it 
was so densely adherent. From the right side, at the same 

164 Exhibition of specimens. 

time, he removed the ovary for a small ovarian cyst about the 
size of a tangerine orange, but had left the tube on that side. 
Two months ago there were symptoms of extra-uterine preg- 
nancy, and he had then removed the right tube with a tubal 
pregnancy, in which there was an attempt at tubal abortion. 
This was a distinct case of migration of the ovum. The left 
ovary had ovulated, and the ovum must have found its way 
into the right tube, though the migration was not a long one, 
for the left ovary was prolapsed and adherent and close to the 
right side. 

(c) Double pyosalpinx, from a young lady recently 
married. She had complained of abdominal pain, the result she 
thought of a boxing match with her husband. On both sides 
of the uterus were great masses, and distinct evidence of the 
gonococcus was found. 

III. JJr Haultain showed — (a) A fibeo-myoma of the round 
ligament, 3 lbs. in weight, quite distinct from the uterus, (b) 
Section showing tubercular endometritis, from a patient 
who had complained of no symptoms. She had been recom- 
mended to him on account of sterility. On examination, an 
anteflexed uterus was found. There was a history of some slight 
pain (heat the patient termed it) after making water. He 
decided to dilate the cervix and curette, and the report of the 
uterine scrapings was that it was tubercular. Then, upon 
examining the urine, tubercle bacilli were found. 

IV. Dr W. Fordyce showed — (a) carcinoma of the uterus 
(three specimens — two cervical, one corporeal), removed by 
vaginal hysterectomy; (b) uterus showing combined fibroid 


necrobiosis; (d) cervical fibroid tumour; (e) multiple 
fibroids of uterus, removed for pressure symptoms; (J) 
multiple fibroids, removed for post-climacteric haemorrhage. 




By Robert Jardine, M.D., Professor of Midwifery in St Mungo's 
College, Glasgow; Senior Physician to the Glasgow Maternity 

In most works on midwifery the subject of epilepsy is dis- 
cussed in a few sentences of general remarks. Again, in some 
books on epilepsy, the effect of pregnancy and labour on the 
condition is hardly mentioned. It is thus difficult to gain 
information on the matter. 

In his recently issued book on epilepsy, Dr W. Arden 
Turner gives his experience of the influence of pregnancy, 
the puerperium, and lactation in forty-one epileptic women, with 
a history of sixty-one pregnancies. He tabulates the results in 
the following way : — 

Quickening induced a relapse in 
P/egnancy was the original cause in 
„ induced relapse in 
„ was temporarily beneficial in 
made no difference in 
Accouchement was the original cause in 

„ induced a relapse in . 

Lactation was the original cause in . 
„ induced a relapse in 

7 cases. 

2 „ 
14 „ 

6 „ 

1 „ 

5 „ 
17 „ 

3 „ 

6 ., 

Total pregnancies 


Forty-one cases. — Of twenty-five of these cases the family or 
other history bearing upon heredity was studied, and thirteen 
cases, or 52 per cent., gave a history of family epilepsy or 
alcoholism, a percentage which corresponds with that ascer- 


tained as the relative proportion of a family predisposition 
amongst epileptics in general. 

In the two cases where pregnancy was given as the original 
cause, the women were both young, and pregnant for the first 
time. In one of the cases where there was freedom from attack 
in one pregnancy, the fits became more frequent in a second 
pregnancy. He says: "There are undoubted cases on record 
in which fits have been permanently arrested by pregnancy, 
and others in which a temporary remission has been observed ; 
but it will be seen from the figures here given, that it is more 
common to find a relapse of the attacks, or the conversion of a 
minor type of the disease into the combined major and minor 
type. Nerrlinger's figures on this subject show that of ninety- 
two women with one hundred and fifty-seven pregnancies, 28 per 
cent, showed complete cessation of the fits during pregnancy, 
and 35 per cent, were made distinctly worse." 

In regard to accouchement and the puerperium, he says: 
" There were five cases in which the disease clearly originated 
at this time, and seventeen in which it led to a serious relapse. 
Of the first series, the onset was in the form of serial epilepsy, 
or the status epilepticus (puerperal eclampsia), and the disease 
continued in a chronic form for many years afterwards. In 
one case it commenced during the fourth confinement, and in 
three others during the first. These cases are particularly 
interesting, as they argue strongly in support of the view of 
Fere, that puerperal eclampsia, like many other ' eclampsias,' 
is merely epilepsy in an acute form, and that the disease, once 
started in this way, may persist for years. Two cases were 
illustrative of this, by the fact that after the original eclamptic 
attack the further continuance of the malady was in the form 
of minor seizures over a period of eighteen and ten years 

" Of the second series — those cases in which a relapse was 
caused by confinement — there were two, in which a remission 


of twelve and eighteen months respectively was broken by the 
eclamptic seizures of the puerperium. In the others they 
merely formed an incident in the course of the confirmed 

"It was not uncommon, in cases of already existing 
epilepsy, for puerperal convulsions to be delayed untiLthe later 

"The incidence of serial epilepsy, at or immediately suc- 
ceeding parturition, is therefore a common feature in epileptic 
women, and raises the question as to the diagnosis of some 
forms of puerperal eclampsia. A history of pre-existing attacks 
would determine the diagnosis of epilepsy ; while the existence 
of a neuropathic family history, or the presence of stigmata of 
degeneration, would point to eclamptic attacks as being of 
epileptic nature. The presence of albuminuria does not of 
necessity form the main element in the differential diagnosis, as 
albumen has been found in the post-paroxysmal urine of 
epileptics (Voisin and Peron), although it is not of common 

" It is therefore clear that many cases of puerperal eclampsia 
are really examples of serial epilepsy, or the status epilepticus, 
induced during the puerperium in predisposed and neuropathic 

I have given these long quotations from Dr Turner, as they 
represent the views of a man who has had a very large 
experience in epilepsy. With most of his statements I am in 
agreement, but I cannot agree with the statement that many 
cases of puerperal eclampsia are really examples of serial 
epilepsy, or the status epilepticus. I have now seen consider- 
ably over one hundred cases of puerperal eclampsia, and, before 
the present series, there were only two which I considered 
were really epileptic cases. In one of them there was no 
albumen in the urine, and in the other there was a considerable 
quantity, but in the latter case there was a distinct history of 


previous epileptic seizures. The two conditions resemble each 
other so closely that it is difficult to distinguish between them, 
but there are so few cases of eclampsia which subsequently 
have fits, even in connection with pregnancy, that I think we 
are justified in concluding that a true case of puerperal eclampsia 
is not one of epilepsy. It is impossible to follow up the sub- 
sequent history of hospital cases, but in my private cases I 
have not met with one in which epilepsy has developed. In 
this connection it will be interesting to hear the experience of 
others, and in that way we may get the results of a fairly large 
number of cases. 

Case I. — Mrs T., tet. 27, iii.-para, full time, was admitted to 
the Glasgow Maternity Hospital on 27th February 1907, at 
7.30 A.M., with a history of having had twelve fits since 
4.25 a.m. 

The patient's father died in an asylum, where he was confined 
apparently on account of melancholia. Her mother is alive and 
well. She had had seven sisters, one of whom died at the age 
of 20, after having had epileptic fits for six years. The other 
sisters are quite healthy, but one is very rickety. She had no 
brothers. She had always been a healthy woman, and had 
never had any serious illness. There was no history of any 
injury and no evidence of syphilis. She had never had a fit 
prior to the morning of admission. 

The patient was married on 6th February 1903 ; her first 
child was born in October of the same year, and the second in 
June 1905. Both children were delivered with forceps at the 
patient's home. She had had no miscarriages. 

During the present pregnancy the patient's health had been 
good. There had been no swelling of the face or legs, and no 
headache until the evening before admission. On that evening 
she had complained of headache, and had not felt well, but there 
was no other symptom until she took the first fit at 4.25 a.m. 


On admission, the patient was quite unconscious, and had 
several fits in the reception room before she was removed to 
the labour ward. The fits were of the ordinary eclamptic type. 
There was no cry at any time. The pulse was full and bound- 
ing, and the respirations were hurried. 

I saw the patient at 10 a.m., and up to that time she had 
had twenty-one fits. She was at once put under chloroform, 
and 16 fl. oz. of blood were drawn from a vein in the right arm, 
and 3 pints of saline solution (1 dr. of sodium chloride and 
acetate to each pint) were transfused. "While this was being 
done, I found that the os was about half dilated, so I finished 
the dilatation manually and delivered the child by version. 
The uterus retracted well, but there was considerable bleeding 
from the cervix, which had been lacerated bilaterally. After I 
had allowed her to lose a good deal of blood I stitched the 
cervix with catgut. The pulse remained fairly full and strong. 

The delivery was finished at 10.45 A.M., and the patient was 
free from fits until 6.20 p.m. (i.e., an interval of eight hours). 
During this time she had been able to swallow 6 fl. oz. of milk, 
3 fl. oz. of imperial drink, gr. viii. of calomel, and later a dose of 
magn. sulph., and although she was not sufficiently conscious to 
answer questions, she could be roused when spoken to. From 
6.20 p.m. to 8.20 p.m. she had fourteen fits. A hot pack was 
given at 8 p.m., and from 10 p.m. on the 27th until 3 a.m. on 
the 28th (i.e., for five hours) she had no fits. At 11.15 p.m. an 
intravenous injection of two pints of the saline solution was 
given into the left arm. After midnight the patient perspired 
freely. The pulse^rate had varied from 96 to 116, the tempera- 
ture from 100*2° to 101 '4° R, and the respirations were 28. 
The urine was found to be quite normal, without a trace of 

28th February. — The fits began again at 3 A.M., and she had 
from four to seven per hour until 10.30 am. At 3.15 a.m. and 
6.30 a.m. 30 grains of chloral and 60 grains of potassium bromide 


were given per rectum. Part of the first injection was returned, 
but the second was retained. At 1Q.30 A.M., an intracellular 
injection of 2 pints of the usual saline solution was given 
beneath the right breast, and the fits became less numerous. 
At 12.45 an attempt was made to draw off some cerebro -spinal 
fluid, but none could be obtained, although the needle was 
inserted four times. Venesection was now performed in the 
right arm and 9 fl. oz. of blood were withdrawn, and 2 pints of 
saline solution, with double the quantity of sodium acetate, 
were infused. The fits remained infrequent until 3 p.m., when 
they again became more numerous and gradually increased in 
number until she had thirteen between 8 and 9 p.m. In the 
afternoon, between 3 and 5 p.m., three-quarters of a grain of 
morphia was given hypodermically, in three doses, without the 
least apparent effect on the fits. At 9 p.m., 30 gr. of chloral 
and 60 gr. of potassium bromide were given by the rectum, but 
the fits continued at the rate of twelve per hour. At 10.30 
P.M., lumbar puncture was again tried, and at this time a little 
over a fl. oz. of cerebro-spinal fluid was withdrawn. The fluid 
was very slightly opalescent, but did not contain more blood 
than could be accounted for by the puncture. A slight deposit 
settled from the fluid, and this was found to consist of poly- 
morphonuclear leucocytes with a larger number of lymphocytes 
(small mononuclear leucocytes). The withdrawal of the cerebro- 
spinal fluid did not produce any change in the patient's condition. 
The fluid escaped from the needle by drops, except during the 
fits, when it ran freely. Between the fits there did not seem 
to be any increase in the tension. 

After the fluid was withdrawn a dose of stovaine was 
injected, and almost immediately there was a lessening of 
movements in the legs during the fits, but the fits continued to 
recur about every five minutes. In a few minutes there was 
absolute paralysis of the lower limbs. The paralysing effect 
spread up to the arms, and movement in them became much 


less marked. The diaphragm was not affected. Shortly after 
the stovaine had been administered, the movements, which had 
all along been much more marked on the right side, now became 
confined to the left side. In a short time the fits ceased to 
affect the left side and returned to the right. The patient 
became extremely collapsed, and the pulse disappeared entirely 
from the wrist. Strychnine (^ gr.) was given hypoclermically, 
and a pint of hot milk and 3 fl. oz. of brandy were injected into 
the stomach through a tube. The pulse rapidly returned to the 
wrist, but the patient remained collapsed for a considerable time. 

1st March. — The patient remained in much the same con- 
dition all day. The pulse kept remarkably good, the skin 
acted well, the bowels moved freely, and plenty of urine was 
passed, partly by catheter and partly unconsciously in bed. 
The patient was fed at intervals with milk, water, and brandy 
by the stomach tube. At 5.50 p.m. 2 pints of the usual saline 
solution were infused into the abdominal walls, and at night 
I gr. of morphia was injected subcutaneously. The fits occurred 
at the rate of from six to fourteen per hour. 

2nd March. — At 8 a.m. the fits became much more frequent, 
and she had twenty between 8 and 9 A.M., and thirty between 
9 and 10 a.m. ; the fits were slighter than on the previous days, 
but the patient passed almost immediately from one to another. 
The pulse was still remarkably good, but the patient's general 
appearance was bad. The fits hardly affected the legs, and the 
movements of the arms were not nearly so marked as during 
the first two days. An attempt was made to examine the fundi 
oculi with the ophthalmoscope, but nothing abnormal could be 
detected except that the discs looked rather too red No optic 
neuritis could be detected. The superficial layers of the cornese 
were beginning to show evidence of destruction, and this, with 
the continuous movements of the head, made the examination 
very difficult. Between 12 noon and 1 p.m. the patient had the 
greatest number of fits during any hour, viz., thirty-two. 


At this time Mr Hogarth Pringle kindly saw the patient 
with me, and we discussed the advisability of trephining, but 
concluded that it would be of no avail. 

From 6 p.m. the patient gradually sank, and she died at 7.40 
P.M. without any other change taking place in her condition. 
The rectal temperature taken immediately after death was 
104-2° F. The number of fits recorded was 774. 

The fits, though so numerous, did not appear to be very 
exhausting. All along they were much more marked on the 
right side than on the left, except for a short time after the 
injection of the stovaine. As a rule, they commenced with 
twitchings of both upper eyelids, especially of the right, followed 
by conjugate deviation of the eyes to the right, the right arm 
and right leg were then affected and the left side only very 
slightly. During the tonic stage the patient did not become 
so cyanosed as is ordinarily seen in epileptic or eclampsia 
seizures, and she never gave a cry. The fits lasted from half a 
minute to two minutes, and the tonic and clonic stages were of 
much the same duration. 

For the first two days no albumen could be detected in the 
urine, and even later there was never more than a very faint trace. 
Towards the end some finely granular tube-casts were found 
on centrifugalising the urine. At no time did the patient 
vomit, not even after the stomach tube had been passed. 
There was some retching after a few of the fits, but that was 
all. There was no jaundice. The knee-jerks were absent. 
The highest temperature recorded was that taken, per rectum, 
immediately after death, viz., 104*2° F. The skin acted well 
during the whole of the last three days, and abundance of urine 
was excreted. There was no oedema at any time. 

The child, a male, was delivered by podalic version. It 
weighed 7f lbs. At birth it was asphyxiated, but was easily 
resuscitated. It remained, however, extremely blue during the 
whole of the 27th February, and the colour never became quite 


satisfactory, especially in the arms and legs. It lived three 
days, and during that time its body was more or less in a state of 
rigidity, the stiffness becoming much more marked at intervals. 
It had many of these fits of rigidity, although there were no 
convulsive attacks. At times the body assumed a position of 
opisthotonos, and it could be lifted by placing one hand under 
the head and another under the heels. When these fits of 
rigidity came on, it gave a peculiarly distressing cry and then 
became very cyanosed. It was very restless, and cried a great 
deal. Its urine contained a considerable amount of albumen. 
Chloral hydrate was given to it in grain doses every hour at 
first, and finally every half-hour, and it gradually grew quieter, 
but whether this was due to the action of the chloral or to the 
increasing weakness it was impossible to say. 

A post-mortem examination was performed on both bodies 
by Dr Carstairs Douglas. 

The Mother. — On exposing the dura mater a number of 
small haemorrhages were seen, some punctiform and others 
slightly larger, due to rupture of venules within the membrane. 
The whole venous system of the membrane was engorged to a 
striking degree, the engorgement being very evident in the 
vicinity of the superior longitudinal sinus. The engorgement 
was much more marked on the left side of the brain. The 
meninges stripped off quite easily, and there was no evidence of 
any thickening or of inflammatory adhesions. The brain sub- 
stance was somewhat firmer than usual. No lesion could be 
detected. About an inch of the upper end of the spinal cord 
was removed, and it appeared to be quite normal. 

Microscopic examination of sections from the motor area 
showed that the nerve cells were normal. A small aneurismal 
dilatation was observed on one of the minute arteries. 

Thorax. — Both lungs were adherent and showed evidence of 
old pleurisy. The lung tissue was fairly normal The heart 
was normal except that the tricuspid valve was dilated. 


Abdomen. — The liver showed a slight nutmeg condition. 
The spleen was congested, pulpy, and enlarged. The kidneys 
were both smaller than normal. The capsules stripped off 
readily. The substance was pale and firm. The cortical area 
in both was diminished in size. The uterus, ovaries, and tubes 
were normal. 

Microscopic examination of sections of the kidneys showed 
evidence of acute nephritis. There were some haemorrhages 
and blocking of the tubules with debris. 

The Child. — The body was plump and well nourished. The 
skull was harder than usual. The meninges were healthy. The 
brain was soft and pulpy, and showed a fair amount of 
vascularity, but not quite as marked as in the case of the 
mother. There was no indication of haemorrhage in any part. 

Abdomen. — The liver was of the usual size ; a little pale and 
spotty in parts and engorged along the margin. The spleen 
was of ordinary size and consistence. The kidneys were lobu- 
lated and normal in appearance, but somewhat smaller than 

Microscopic examination of the kidneys showed evidence of 
congestion, but not so marked as in the mother's. There were 
some haemorrhages, and some of the tubules showed exudate. 

Remarks. — The differential diagnosis between epilepsy and 
eclampsia is very difficult, and some alienists seem to think the 
two conditions are identical. If there is a history of previous 
epileptic seizures, I think one would be justified in looking upon 
the case as epileptic. The condition of the urine will not be of 
much assistance unless there is a large quantity of albumen in 
it. I have never yet seen a case of eclampsia in which there 
was no albumen in the urine. I am aware that such cases have 
been recorded, but may not these have been cases of epilepsy ? 
In the case just recorded there was no albumen in the urine at 
the onset. At first I looked upon the case as an ordinary 


eclamptic, but when I found there was no albumen in the urine, 
and the fits began to recur, I concluded that we were dealing 
with a case of epilepsy. Towards the end of the case there was 
a trace of albumen in the urine, but that was what was to be 

The status epilepticus is a condition seen frequently enough 
in asylums. During a seizure the number of fits may be very 
great. Dr Turner says that in a case of Leroy's there were 488 
fits in twenty-four hours and 1000 in three days, and in a case 
of Parsons' there were 1400 in four weeks. Turner has seen 
2080 in eight weeks, 673 in ten days, 820 in five days, and as 
many as 289 in twenty-four hours. In my case there were 774 
fits in the eighty-eight hours from the onset until death, but 
during fourteen of these hours the patient was free from fits, so 
that the 774 fits occurred in seventy-four hours, an average of 
over ten per hour, and in one hour there were thirty-two. In 
the last twenty-four hours there were 407, and in the last 
twelve hours no fewer than 261. It seems almost incredible 
that any constitution could stand such a terrible strain for so 

In regard to treatment, drugs seem to have no effect. It 
will be noticed that the fits ceased for eight hours after bleeding, 
saline infusion, and delivery. After a hot pack they also ceased 
for one hour, and again for five hours after a cellular transfusion. 
After the intracellular infusion and the second bleeding and 
third (intravenous) infusion, they lessened, but did not entirely 
cease. The final intracellular infusion seemed to have no 
effect. Eleven pints of saline solution was used, seven of them 
directly into the vein. In the third infusion I doubled the 
quantity of sodium acetate. I did this in the hopes of neut- 
ralising any lactic acid which might have formed in the blood. 
Lactic acid has been found to be present in the blood of 
eclamptics, and it has been suggested that the efficiency of my 
solution is due to the neutralising effect of the sodium acetate. 


The patient's blood must have been well diluted, and as the 
kidneys and skin were acting so well, one would have expected 
that if a toxin were present it would have been flushed out. 

The removal of the cerebro-spinal fluid did no good. The 
tension did not seem to be raised except during the fits. I 
tried the injection of stovaine, but the effect was very alarming, 
and for a time I thought the heart would be paralysed. The 
injection of hot milk and brandy into the stomach and -fa of a 
grain of strychnine hypodermically had a splendid effect upon 
the heart, and soon brought the pulse back to the wrists. If I 
should ever have another such case to treat, I shall be inclined 
to try the effect of an injection of potassium bromide. 

[By a curious coincidence at the date on which I read this 
paper, I had under my care in hospital two cases of epilepsy, 
and I also admitted a third one about ten days later. I shall 
give short notes of these three cases. 

Case II. — A., jet. 34, ii.-para, was admitted to hospital on 
28th April 1907, under the care of Dr Munro Kerr, and she 
came under my care on 1st May, when I took up duty. 

The patient's first child was born four years ago, and died 
in November 1906, with cerebral symptoms following a 
discharge from the ear. Previous to her first pregnancy the 
patient had never had any convulsions, but when the pregnancy 
was three or four months advanced, fits had commenced to occur, 
and at that time as many as fifty had occurred in twenty-four 
hours. Since this pregnancy she had had attacks of petit mal 
every few weeks. These attacks had become less frequent of late. 

On 24th April the patient complained of headache, and on 
the 25th she had one fit, on the 26th four fits, on the 27th 
eight fits, and on the 28th nine fits. 

On admission, the patient was conscious between the fits, 
and, though dazed, she was able to answer questions intelli- 


gently. She was seven and a half months pregnant. There 
was no indication of labour. There was a very faint trace of 
albumen in the urine, but no oedema. 

At 5 p.m., 2 J pints of saline solution were infused into the 
median basilic vein, and 7 grains of calomel followed by 
magnesium sulphate were given and £ gr. of morphia 
hypodermically. Four fits occurred before midnight. 

29th April. — Hypodermic injections of £ gr. of morphia 
were given at 1.30 a.m. and 4.50 a.m., and also 30 gr. chloral 
and 60 gr. of potassium bromide per rectum at 3 p.m., but the 
fits continued. Strychnine ^ gr. was given four-hourly. 
Twenty- three fits occurred during the day. At 8 p.m., Dr 
Kerr performed vagina] Cesarean section and emptied the 

30 th April. — The patient had forty-two fits. 

1st May. — The patient had nine fits. 

2nd May. — The patient had two fits. 

3rd May. — The fits had ceased, but the patient was very 
delirious. The restlessness and delirium continued for three 
days, and after that recovery was rapid. 

It will be noticed that the greatest number of fits occurred 
on the day after delivery. There were 102 fits in all. The 
case might be termed one of the status epileptic us. The 
fits first began during pregnancy, so that according to Turner's 
classification pregnancy would be given as the original cause. 

Case III. — Mrs M. S., set. 21, iii.-para, was transferred to 
the Maternity Hospital from the Eoyal Infirmary, where she 
had been under treatment for epilepsy for some weeks. 

Her mother was eight years ago confined for some time in 
an asylum. There is no other history of mental disease in the 
family. The patient's two children are alive and healthy. 

The patient states that as a girl she enjoyed good health, 
but her parents have told her that she had convulsions when 



she was 12 years old. She has no recollection of them. She 
was married four years ago, and her first child was born in 
June 1904. When six months pregnant she began to take fits, 
and as pregnancy advanced they became more frequent, two 
or three a week. Just before labour they become much more 
frequent. She says she was unconscious during the labour, and 
for a couple of hours afterwards. She had about two fits a 
week during the puerperium. She could not nurse her baby. 

During the second pregnancy she had about three fits per 
week. The child was born in December 1905, at full term. 
The patient was again unconscious during the labour. As on 
the first occasion, a midwife attended. 

The third, present, pregnancy began about seven months 
ago. Between the second and third pregnancies she had had about 
three fits a week. About seven weeks before admission to the 
Maternity Hospital the fits became more frequent, and she 
fell and injured her face during an attack. She was admitted 
to the Koyal Infimary, and after four weeks' treatment in the 
Infirmary the fits ceased. She had four fits on the day 
of admission. She had never had any treatment for the fits 
prior to this. She was transferred to the Maternity Hospital, 
as a slight vaginal discharge of blood had commenced. 

There was no indication of labour; the urine contained a 
trace of albumen ; the bromide mixture of 15 gr. doses thrice 
daily was continued. 

Two days after admission labour came on, and a premature 
female child (3 lbs.) was born alive, but only lived five hours. 
There were no fits during the labour, and there was only a 
very slight one in the puerperium, on the first day she was 
allowed out of bed. 

The patient stated that she never had any warning of an 
attack, and she was usually unconscious for some hours after a 

In this case there is the history of convulsions at the age 


of 12, so that there was a predisposition, but pregnancy was 
the exciting cause. In both of these cases there was a trace of 
albumen in the urine. 

Case IV. — Mrs B., v.-para, set. 26. 

The patient's mother committed suicide, after a former 
unsuccessful attempt, by eating rat poison. Of her father's 
brothers one died in an asylum two years ago, and another 
is in an asylum at present. 

At the time of her mother's death she was ten months old, 
and was being nursed by her mother. Shortly afterwards she 
is said to have begun to take convulsions, and she can 
remember having had convulsions as a child. After the age of 
13, the attacks were not always of a convulsive nature. She 
sometimes lost consciousness, but did not struggle. Her 
friends informed her that in some of the attacks she acted 
and spoke in an unusual way, but she has no recollection of 

She was married seven years ago, and since marriage the 
attacks have never been convulsive, but have consisted of loss 
of consciousness, with strange actions or remarks. She is now 
pregnant for the fifth time. One of the previous pregnancies 
was a twin pregnancy. One of the twins died at the age of 
three and a half months, but all the other children are alive and 
in good health, except one which is rickety. Her labours have 
been slow but natural. During pregnancy the attacks have always 
been much less frequent than at other times. When she was 
nursing, the attacks were more frequent — about once a 

The labour was natural, and the patient had no attacks 
while in hospital. 

In this case pregnancy seems to have had a beneficial effect 
on the attacks, but it will be noticed that the attacks were most 
frequent during lactation. In this case there would be a 


strong hereditary predisposition. So far, the children show no 
tendency to neurotic attacks.] 

I am indebted to my residents, Drs Melson and Walker, 
for the careful notes of these cases, and to Dr Carstairs 
Douglas for the post-mortem reports. 

Dr Ritchie said they owed a deep debt of gratitude to 
Prof. Jardine for having submitted so very interesting a record 
of the case. He agreed with Dr Jardine that if one obtained 
a history of pre-existing fits, one was justified in diagnosing 
epilepsy in that particular case; and that if there was no 
previous history of fits, then the case was one of puerperal 
eclampsia. He had had a good many cases of puerperal 
eclampsia, but in none of the cases was there afterwards a 
development of epilepsy. As to treatment, if one diagnosed 
epilepsy, the treatment was that for epilepsy ; one would not 
expect in such a case to find benefit from the treatment which 
is necessary for puerperal eclampsia. 

Dr Haultain said he could only follow suit to what Dr 
Eitchie had said. The question of epilepsy was a subject of 
very great interest to him, as he had had a considerable 
experience in the subject both in the Maternity Hospital and 
in consulting practice. He was only sorry the subject had 
been sprung on them, as it were, when otherwise he might have 
been able to have gone over some notes of cases he had seen. 
On a haphazard recollection he would divide epilepsy in preg- 
nancy into two great groups — (1) where previously there had been 
epilepsy, and (2) where there had not previously been epilepsy. 
In the first group his experience seemed to show that the effect 
of pregnancy was most irregular. In several cases pregnancy 
had absolutely no effect at all upon the disease. In another 


set of cases the condition was exaggerated. In two cases 
before his mind, one was in a condition of status epilepticus. 
She was from five to six months pregnant. He decided to 
procure abortion, and did so, but in spite of his efforts the 
patient died. In the second case the patient was having an 
exacerbation of fits, and from previous experience he thought 
the pregnancy should be ended. Abortion was procured ; the 
patient survived, but lapsed into the old condition — having fits 
occasionally, but in no way exaggerated. There was a third 
set of cases where undoubtedly epileptic fits seemed to be dimin- 
ished. He had read of, and thought he had seen cases where 
the presence of pregnancy seemed to alleviate the tendency 
instead of exaggerating it. As to cases where epilepsy first 
commenced during pregnancy, others of course brought out 
the question of the differential diagnosis between epilepsy and 
eclampsia. There was no doubt that he was in accord with 
what Dr Jardine had said regarding the question of epilepsy 
in pregnancy and labour. He did not believe these were cases 
of eclampsia at all unless there was albuminuria. He had 
never seen true eclampsia where there was not highly 
albuminous urine, much diminished in quantity. He had 
certainly seen one case where epileptic convulsions developed 
during pregnancy and returned during a subsequent pregnancy, 
and in the interval there were no fits at all. Again, in another 
case where the patient had undoubtedly puerperal eclampsia, 
highly albuminous urine diminished in amount after the 
confinement was over ; in eight to ten days she again took fits 
at a time when there was no albumen in the urine. This case 
temporarily upset his ideas on the subject of puerperal eclampsia 
and albuminuria, and he thought the case was one of epilepsy ; 
and so it turned out to be, as the patient had taken fits several 
times since, independently of pregnancy. The origin had been 
with puerperal eclampsia, and had remained as epilepsy after- 
wards, showing (he difficult problems there were to be considered. 


One would expect the condition of epilepsy to be aggravated by- 
pregnancy — a time when there is a toxaemic condition ; yet, in 
spite of this, epilepsy in some cases is not so virulent as 
before, and it therefore seems that we have nothing to prove 
either in one thing or another as to the effect of pregnancy 
upon epilepsy. As to treatment and the question of marriage. 
People who had epilepsy should never marry under any cir- 
cumstances, on account of the hereditary transmission of the 
disease. If fits should become aggravated, the uterus should be 
emptied to prevent any condition of status epilepticus occurring, 
or even the undermining of the mental condition from frequent 
convulsions, As to the treatment by strychnine, it seemed a 
somewhat radical measure. 

Professor Jardine here explained that strychnine was given 
to keep the patient alive. 

Dr Haig Ferguson had very little to add but to convey his 
thanks to Professor Jardine for his interesting paper. Both Dr 
Jardine and Dr Haultain had stated that they had never seen 
cases of eclampsia where there was no albumen in the urine. 
He had strong and good grounds for believing that eclampsia 
could exist without any albuminuria. What was more im- 
portant was the question of the diminution in urea. He had 
seen cases of typical eclampsia where to begin with there had 
been no albuminuria, but where the amount of urea was con- 
siderably diminished. He had always been of the belief that 
puerperal convulsions should not be regarded as epileptic if 
the patient had no previous history of epilepsy, though a patient 
with a previous history of epilepsy might take puerperal con- 
vulsions. One case occurred to his mind, where the woman in 
her first pregnancy took a large number of convulsions which 
were supposed to be eclamptic. There was no diminution in 
the urea and no albuminuria. On making a close inquiry into 
the previous history, it was discovered that the woman had had 
attacks of petit mat at every menstrual period. In this case 


the condition of epilepsy had been aggravated during pregnancy. 
He had never seen a case where the fits were cured by preg- 
nancy. All the cases he had seen had appeared to have had the 
condition somewhat aggravated by the pregnant condition. He 
would say that any woman who had epileptic convulsions 
during pregnancy had had epilepsy on some previous occasion. 
They were greatly indebted to Dr Jardine for his paper. 

Dr Porter had had one case, eight months ago, a primipara, 
19 years of age, who had had regular epileptic seizures, 
aggravated at every menstrual period. At the seventh month of 
pregnancy she had developed slight albuminuria. The labour 
was quite normal. She had two fits about the fifteenth day of 
the puerperium, which were easily controlled by bromide. 
The child had been delivered naturally. 

The President said his experience was along the lines of 
these mentioned. He remembered one case at the Dispensary 
where the patient had epilepsy except during the times of 
pregnancy, the epilepsy returning again a month after the 
pregnancy was over. He afterwards came across one or two 
other cases where this did not apply, and he had had quite a 
number of interesting cases at the Maternity Hospital. The 
main result of them had just been that some were better during 
pregnancy, and some were worse. Some were free during 
pregnancy, and some were free except at the time of pregnancy. 
There were not many where there was any special development 
during pregnancy. With regard to the relationship of eclampsia 
and epilepsy, they must come to the conclusion that the 
eclampsia we had in this country differed in some way from 
that in America and other parts of the world. Americans 
constantly assured him that they had a number of cases where 
there was no albumen in the urine, and said that a great 
number of their cases were nervous, and to be included under 
epilepsy and hystero-epilepsy rather than eclampsia. 

Prof. Jardine, in reply, said there was a fair amount of albumi- 


nuria in all cases of eclampsia, and also diminution of urea. 
He wished some of those accustomed to deal with such cases 
in asylums had been present at the discussion. It was an 
extremely difficult thing to decide about the . question of 
epilepsy in connection with pregnancy. They knew that the 
effect of pregnancy on the nervous system of women varied 
very much, and they could imagine that the same differences 
would show themselves in those who were the subject of 
epilepsy. He had only had one or two cases of epilepsy where 
the patient had seemed to be better during pregnancy. Last 
year he had reported a case of recovery after two hundred fits. 
He had looked on that case as eclampsia, but it might have 
been epilepsy, although she had never had a fit before. 


By Dr Malcolm Campbell. 

While the keen attention which has recently been directed to 
the identification of endotheliomata has undoubtedly upset the 
recognised order of relative frequency among ovarian tumours, 
yet dermoids must always, from their nature, continue to 
maintain their position as the most interesting form of tumour 
with which the gynaecologist comes in contact. Though 
dermoids can no longer be regarded as rare tumours, yet they 
undoubtedly are still relatively rare. In the seven volumes of 
Transactions which this Society has issued during the present 
century, there are records of only fifteen dermoids having been 
exhibited. A liberal computation of the frequency of dermoids 
puts them down as from 3 to 4 per cent, of all ovarian tumours. 
Of all forms of ovarian tumour, the dermoid is the one 
most frequently associated with pregnancy. M'Kerron has 
tabulated 113 cases in which ovarian tumours complicated 


pregnancy — of this series no fewer than forty-six were dermoids. 
Besides being the type of ovarian tumour which most frequently 
complicates pregnancy, the dermoid is the most dangerous, for 
in this series of forty-six cases there were eighteen maternal 
deaths due to injury of the tumour during labour. 

While dermoids, both as ovarian tumours and in their 
relationship to pregnancy and parturition, offer an interesting 
field of study, the subject of bilateral ovarian dermoids is even 
more interesting. In regard to the frequency of the condition, 
the experience of gynaecologists varies within wide limits. 
Howard Kelly, in a series of eighty-seven cases in which he 
operated for ovarian dermoids, only found the condition bi- 
lateral in one instance. Munde, in a series of fifteen operations 
for dermoids, found the condition bilateral in three cases. 
G-ebhard, out of 107 cases, found bilateral dermoids no fewer 
than sixteen times. 

In 1902, Loewy and Paul Gueniot published a paper on 
the subjeet of bilateral dermoids, in which they were able to 
collect ninety-eight cases. In thirty of these cases the patient's 
reproductive history was given. In five patients there was a 
history of one pregnancy, while five others had each given 
birth to two children. The other cases had all had more than 
three children, and in one case there was a history of seven 
full-time pregnancies and five abortions ; while another patient, 
prior to operation, had borne twelve living children, and in 
addition had one abortion. 

I have been able to find references to only nine cases in 
which bilateral ovarian dermoids were removed during preg- 
nancy ; and I have also found the notes of a case, published by 
F. Page, who operated on a patient for peritonitis, two and a 
half months after labour, — when the abdomen was opened, 
bilateral ovarian dermoids were found. 

Of the nine double ovariotomies for dermoids during 
pregnancy, I have only been able to see the original communi- 


cation in one case, viz., that of Knowsley Thornton, in which, 
on 4th February 1886, he removed bilateral dermoids from a 
patient who was delivered of a full-term foetus on 23rd June of 
the same year. 

Though the preceding notes can in no sense be regarded 
as a review of the literature of the subject, the figures I have 
quoted seem to me to amply justify my bringing the following 
case to the notice of the Society : — 

The patient, Mrs F., set. 32, was admitted to Dr Brewis's 
ward on 2nd June 1906. She had been married twelve years, 
and had five children, the eldest set. 10, the youngest aet. 2 
years and 3 months. Beyond some premenstrual dysmenorrhea 
before marriage, there was nothing to note in regard to 
menstruation, which began at 14, was of twenty-eight-day 
type, and lasted four days. There had been amenorrhoea from 
March 1906. 

Before the onset of her present illness, six months prior to 
admission, patient had enjoyed perfect health. 

On admission, the patient complained of pain in the right 
side, which she stated went round to her back. The onset of 
the pain in January 1906 was sudden, and the pain so severe 
that patient had to remain in bed for a week, and was only 
able to lie on her left side. During this attack there was 
some vomiting. There was no vaginal discharge. Since the 
initial attack there had been several returns of the pain at 
intervals. The pain came on without any discoverable cause, 
lasted for about an hour, and then passed off. The pain was 
worst in the right iliac fossa, then from there it radiated to the 
back. She occasionally had vomited with these attacks. 

About three months before admission, patient first noticed a 
swelling on the right side of the abdomen. The last attack of 
pain occurred about a week before admission. 

Physical Examination. — The abdomen was seen to be 


slightly distended by a swelling passing from the right lumbar 
region to midway between the sternum and the umbilicus. 
This swelling moved freely with the respiratory movements. 
On palpation, a tumour was found extending from the mid-line 
to the anterior axillary line on the right side. The tumour, 
which was flattened antero-posteriorly, seemed to be disc-shaped, 
and was about 4 inches in diameter. The tumour was not 
sensitive on palpation. It was not uniform in consistence, and 
could be moved freely. If pulled upon, a tense band could be 
felt running down into the pelvis. The uterus could be felt in 
the hypogastric region. There was no free fluid, in the abdomen. 
On vaginal examination the uterus was found enlarged, and 
undergoing rhythmic changes in consistence. There was marked 
pulsation in both lateral fornices. In the left lateral fornix, 
posteriorly, a hard irregular non-sensitive body about the size 
of a hen's egg could be felt ; this was evidently the displaced 
left ovary. The right ovary could not be felt. 

On 6 th June the abdomen was opened, and the tumour 
above described was found to be an ovarian tumour with a very 
long pedicle, growing from the right side : it was removed in 
the usual way. On removal it was about the size of a foetal 
skull, and on being incised was seen to be a dermoid tumour 
containing sebaceous matter, hair, and teeth. 

The left ovary was examined; an attempt was made to 
resect this ovary, in order to conserve for the patient some 
ovarian tissue ; as this, however, was found impracticable, the 
whole ovary was removed. On examination, it was found 
also to be a dermoid cyst containing sebaceous material and 

The patient made a most satisfactory recovery. Before 
leaving hospital, a month after the operation, patient felt foetal 
movements, but on auscultation no festal heart sounds could be 

Since leaving hospital on 7th July, patient has beon 


perfectly well She was delivered of a living child on 9th 

The fact that both ovaries were removed at the end of the 
third month of gestation adds another point of interest to the 
case, for Heil has shown that abortion is most likely to occur 
in the cases in which the corpus luteum is removed before the 
fourth month. 

In regard to the endeavour to conserve a portion of ovarian 
tissue, it is interesting to note that Matthei, Schroeder, and 
Terrier have all recorded cases in which pregnancy followed 
the removal of bilateral ovarian dermoids, where it had been 
found possible to conserve some ovarian tissue. 

In conclusion, I should like to express my thanks to Dr 
Brewis for permission to communicate this case, and to Dr 
McMaster for some notes on the case. 

Dr Haultain was much interested in the case Dr Campbell 
reported. Personally, he had not had any experience of remov- 
ing bilateral dermoids, though on several occasions he had 
removed a dermoid from one side. In this connection there 
was an interesting case of a person he saw four or five years 
ago, in whom he had diagnosed ovaritis. The patient suffered 
a very great deal of pain, and said life was not worth living. 
He had no room for her in his home at that time, but sent 
for her to come in three weeks later, and without examining 
again, proceeded to operate. He thought at the time of opera- 
tion that the uterus was a little large and purplish in colour, 
but removed the ovaries. The patient was delivered at full 
time of a healthy child. This case showed that even at that 
early date removal of the ovaries seemed to have no effect on 
the growth of the foetus. At the present time there were a 
large number of researches on the corpus luteum of pregnancy. 
So far, they seemed to show the corpus luteum had very little to 


do with pregnancy. He thanked Dr Malcolm Campbell for 
having brought forward the case. 

The President had not met with a case of double dermoid, 
but had had four or five cases of single. As to ovarian secre- 
tion, the theory which had always seemed to him to be an 
extraordinary one, was that the corpus luteum was the secretory 
gland of the ovary travelling about from different parts of the 
ovary in different months, simply being functional in one part 
for one month, and then in another. If one looked at it from 
the point of view of luteum, what was luteum? It was a 
perfectly innocuous thing, and going on that line he had 
always been sceptical about theories brought forward as to the 
curative value of lutein and the corpus luteum. 

Dr Malcolm Campbell, in reply, said he had kept purposely 
off the corpus luteum. But although, as some maintained, the 
corpus luteum might do nothing, it should be treated with 
some respect, and left where possible. 

Meeting VII. — June 12, 1907. 
• Dr J. W. Ballantyne, President, in the Chair. 

I. Dr Brewis exhibited — (a) A full-sized crochet-needle, 
removed from the right iliac region of a patient who had 
pushed a needle into the vagina and lost it. Five weeks later, 
on admission, a hard parametric mass was felt anterior to the 
supravaginal part of the cervix ; and to the right, about an inch 
above the middle of Poupart's ligament, there was a projecting 
mass which was suspected to contain one end of the lost 
needle. On cutting down on the mass, this was found to be 
the case, and the needle was extracted. 

(6) A large slough from the interior of the uterus, 


produced by the use of chloride of zinc in a case of inoperable 
carcinoma. On microscopic examination, the specimen was found 
to consist of vascular fibrous tissue and unstriped muscle. 
These were both necrotic in parts and infiltrated with leucocytes, 
while there was also some infiltration of epithelial cells, suggest- 
ing the presence of carcinoma. The slough was fully an inch in 
diameter, showing that destruction of the uterine wall by the 
zinc had been extensive. 

(c) A cystic swelling, somewhat pear-shaped, with a long 
axis of 8 J inches, and a circumference of 11 inches at the 
broad end of the pear. It was a monocyst, formed by the 
junction of cystic right and left Fallopian tubes, and a dis- 
tended and unrecognisable right ovary. The contents were 
caseous-like, and consisted of fatty matter and cholesterin 
crystals, while on certain parts of the walls, internally, were 
deposits of calcareous matter. 

(d) Uterus, containing a large submucous fibroid, 
attached by a broad pedicle to the fundus. The uterus was 
removed by supravaginal hysterectomy along with both ovaries, 
one of which was converted into a monocyst the size of a 
tennis ball, while the other contained a haematoma. 

(e) Large soft edematous fibroid tumour, removed by 
hysterectomy. The tumour presented physical signs closely 
resembling a six months' pregnant uterus. 

(/) Uterus removed by vaginal hysterectomy for bleeding, 
and, from the same patient, a hematoma of the left broad 

II. Br Haig Ferguson showed — (a) extra-uterine preg- 
nancy, nearly four months' duration. The tube had ruptured 
in the country. When seen in town, there was a swelling 
behind the uterus, and extending well up into the abdomen, 
and one waited to see if it was growing, and as it was found 
to be rapidly growing, it was removed by abdominal section. 
The tube had ruptured into the cavity of the broad ligament. 


(b) Specimen from patient, a multipara, aet. 44, suffering 
from irregular haemorrhages. The uterus was scraped 7th June, 
and the pathologist's report was as follows : — " Gland tubes of 
highly irregular shape, lined with columnar cells, irregular in 
arrangement, forming numerous papillae within the lamina of 
the tubes. The epithelial formation is disproportionately great 
in comparison with the connective tissue. A specimen of the 
early stage of a rapidly developing papillary adeno-carcinoma 
of the body of the uterus." The uterus was removed by vaginal 
hysterectomy. This was the fifth case of malignant fundus he 
had operated upon in the last year by vaginal hysterectomy, 
with satisfactory results. 

III. The President showed a photograph of a native mid- 
wife of Nazareth, with a trained midwife from this country 
standing beside her. 


By N. T. Brewis, M.B., F.R.C.S.E., Gynaecologist, Royal Infirmary, 


When I listened to Dr Munro Kerr's paper delivered before 
the Society some three years ago, in which he described in a 
very lucid manner the operation of vaginal Caesarean section, 
introduced by Diihrssen, it brought to my mind more than one 
case where, had I been conversant with the procedure, I would 
have been glad to take advantage of it. One case particularly 
I recalled of a patient in the country, four months pregnant, 
brought to the point of death by severe and uncontrollable 
vomiting, whose cervix was so rigid that Bossi's dilator was 
unable to effect dilatation of the internal os to any extent, and 
the foetus and placenta had to be extracted bit by bit through 
an opening no bigger than a keyhole. When I considered that 
the time, energy, and force spent in the attempt to overcome 
the resistance could have been saved by a few cuts with the 


scissors, the value of Diihrssen's operation came home to me 
and made me determine to practise the method on the first 
suitable occasion. 

The opportunity soon occurred. The following notes of my 
first case were kindly furnished me by the patient's medical 
attendant, Dr Henderson, Kirkcaldy : — 

Case I. — Vomiting of Pregnancy. — "Mrs H., aet. 30. 
Previous and family history good. In January 1903, when two 
months pregnant and in her first pregnancy, she began to 
suffer from severe and intractable vomiting. The usual 
medicinal remedies were of no avail. Eectal feeding had to be 
adopted. Operative interference was seriously considered, 
when she spontaneously aborted. She made a rapid recovery. 

" On 29th November 1905, when three months pregnant 
and in her second pregnancy, she was again prostrated by 
severe vomiting. As before, medicinal remedies were found of 
no avail. All nourishment given by the mouth was returned. 
The vomiting and retching was persistent, and independent of 
the taking of food or medicine. On 6th December 1905, Mr 
Brewis dilated the cervix under chloroform. The vomiting 
gradually subsided, till in ten days' time the patient was able 
to retain and enjoy food, and was up and about. 

" On 1st February 1906, vomiting again set in, producing very 
rapidly great prostration, emaciation, and dusky complexion. 
The patient presented the appearance of one overwhelmed 
with a profound toxaemia. On 3rd February her condition was 
desperate. On that day Mr Brewis performed vaginal Cesarean 
section. She had slight vomiting for two or three anxious days, 
and then absolute recovery." 

I operated twice on this patient — first in November, for 
severe vomiting, when the patient was three months pregnant. 
Though the vomiting was severe the patient was not seriously 
ill, and I performed the operation which I had found most 

BY DR N. T. BREWIS. 193 

useful in those cases, viz., dilatation of the cervix, followed by 
the administration of chloral per rectum. 

At my second visit, three months later, the patient's life 
was in danger so imminent that I considered it indicated to 
empty the uterus as quickly as possible. 

A month later I had another opportunity of putting the 
operation to the test in a case equally serious, but belonging to 
quite a different category. 

Case II. — Eclampsia. Delivery by vaginal Cesarean section, 
at seven and a half months, of a living child, followed by complete 
recovery of mother. — Mrs B., set. 26, was married in November 
1905, and came under my care on 20th March 1906, when she 
was six months pregnant. The following is the history of the 
case : — A week before admission she first noticed her feet 
swollen. The swelling was slight, and not painful. A few days 
later her face and hands also swelled, and she felt pain low 
down across her back. About three weeks ago she had a bad 
cold and cough. This condition lasted a week, and was almost 
like whooping-cough, and prevented sleep. A week before 
admission she got cold again, and had a slight cough on 
admission. Her last period began on 5th November, and lasted 
three days. 

She had suffered from headaches, chiefly occipital in 

She had scarlet fever when about six years old. There was 
no history of kidney trouble. 

On admission, the face was puffy, especially the eyelids. 
There was slight oedema of both hands. Both feet and legs 
were oedematous, the right ankle more so than the left. 

She suffered from breathlessness on exertion. The pulse 
was regular and of high tension. 

The thyroid gland was enlarged. The breathing was harsh, 
but there were no accompaniments. 



Albumen was present in the urine in large quantity. 

Two days before operation patient had a fit, followed by a 
semi-conscious condition. On the next day she had two fits. 
On the morning of the day of operation she had a fit, after 
which she remained in a semi-unconscious condition all day. 
No urine was passed that day. The operation was performed 
in the evening. 

The operation is as follows : — 

The patient was put in the lithotomy position, and after the 
customary preparation for major pelvic operations the vaginal 
portion of the cervix was drawn down to the vulva. 

The anterior vaginal wall was divided transversely im- 
mediately above the external os, and along with the bladder 
was pushed upwards. The anterior surface of the cervix was 
cleared in this manner, and then divided vertically in the 
middle line with scissors for 3 or 4 inches. The membranes 
were then ruptured, and forceps applied to the child's head, 
which was lying in the most common position. Gentle traction 
was used, and after a quarter of an hour's manipulation the child 
was delivered. The placenta was expressed a short time later. 

The cervical incision was sewn together with catgut. Then 
the anterior wall of the vagina and the bladder were stitched 
into position. The uterus was irrigated with weak lysol 
solution, and the patient put to bed. 

Although the traction required was considerable, there was 
no tearing of the wound farther up. Probably the cervical 
wound might have been made 1 inch longer without injury. 

The patient, after a tardy recovery, complicated by a severe 
attack of broncho-pneumonia, returned home on 11th May. 
She is now in good health. The child, although premature, was 
by the aid of an incubator kept alive, and though it had a 
considerable struggle for existence, was sent home when about 
a month old. It is now a strong and healthy child. 

With regard to the applicability of this operation to cases 

BY DR N. T. BREWIS. 195 

of eclampsia, I would say that if it is conceded that in grave 
cases the uterus should be emptied rapidly, Diihrssen's opera- 
tion, owing to the safe, simple, and rapid manner in which it 
can be performed, is a most rational and proper procedure, and 
one which is much to be preferred to the classical Cesarean 
section. In less urgent cases the slower methods of dilatation 
may still have a place, though, if good results are to be got, 
I think the principle of not waiting too long should be adopted. 
Statistics show better results by this method than by any 
other. Veit performed the operation thirty-three times for 
eclampsia with only one death, and Diihrssen has collected 112 
cases having a mortality of 15 per cent. 

Case III. — Stenosis following Amputation of the Cervix. — 
The patient, Mrs B., was operated on by me in March 1905, for 
a large retroverted uterus and hypertrophied eroded cervix. 
The vaginal portion of the cervix was amputated. The uterus 
was curetted and replaced, and the round ligaments shortened. 

I next saw the patient in May of the following year, and she 
was then five months pregnant. She went into labour at end of 
September 1906, and when I saw her some waters had escaped, 
the head was presenting ; no external os could be felt, but the 
lower uterine segment was thinned and spread over the pre- 
senting part. The patient had suffered from pains at intervals, 
and was apparently in labour. Eupture of the extremely thin 
uterine segment was feared. The patient was prepared for 

A transverse incision was made through the vaginal wall in 
front of the presenting part. The bladder was pushed up, and 
the lower uterine segment divided vertically as high as the 
internal os. The foetus was delivered with forceps, and the 
placenta expressed. The patient made a good recovery. 

Case IV. — Heart Disease — Mitral Stenosis and Incompetence, 


with (Edema of Lungs. — Operation performed at five and a half 
months. The following are the notes which were kindly given 
me by her medical attendant, Dr Fleming : — 

" I first attended Mrs D. in June 1906, for cough due to 
slight oedema of the lungs. Her heart was dilated. The 
impulse was felt fully 1 inch outside the nipple line, accom- 
panied by a thrill due to mitral obstruction and incompetence. 
At intervals, chiefly at night, she had attacks of dyspnoea and 
heart pain. She was able to walk a short distance. 

" She told me on the 18th November that she had not men- 
struated since the middle of August, and that but for slight 
squeamishness she felt nothing wrong. In fact, she had not 
felt so well for a long time. I had been called to see her at 
the time because of slight bleeding, probably induced by being 
shaken in a motor bus. This was relieved by a few days' rest 
in bed. During the early weeks of December she had attacks 
of dyspnoea and cardiac pain, and was put on inf. digitalis — 
which she had been taking at intervals since 1904 — and tabell. 
trinitrini. Under this treatment the cardiac pain diminished, 
the pulse got stronger and more regular, and she was able to 
walk better. About the 24th of December she went on a visit 
of three weeks duration to Glasgow, and while there had a bad 
attack of dyspnoea and cardiac pain. The induction of pre- 
mature labour was considered at this time, but it was finally 
decided to allow the pregnancy to go on. 

"On 17th January 1907, her heart was very irregular in 
action. She had not had sleep for some weeks on account of 
the dyspnoea and cardiac pain. There was oedema of the lungs. 
On the 19th January Dr Brewis came to see her, took a very 
grave view of the case, and advised operation." 

On admission, the uterus was found to be enlarged to the 
size of a six months' pregnancy. The cervix was firm to the 

The vulvar aperture was enlarged by making an 'incision 

BY DK N. T. BREWIS. 197 

about f of an inch long into the anterior part of the perineum. 
The cervix was pulled down, an incision was then made through 
the vaginal wall at the junction of the vagina with the cervix 
in front. The anterior aspect of the cervix was exposed by 
pushing up the bladder. The cervix was then cut open by 
scissors through the whole length of the anterior part until 
the uterine cavity was opened into. An incision about \ an 
inch long was made in front into the lower part of the body of 
the uterus. The membranes were exposed. These were ruptured, 
and the liquor amnii allowed to escape. The breech was found 
to be presenting. The lower limbs and trunk were delivered, 
and difficulty was experienced with the after-coming head. 
Forceps were applied, and the head delivered. The child was 
dead. It was a well-developed five and a half months' foetus. 
The placenta was then separated and expressed. The incision 
into the anterior and lower part of the body of the uterus and 
the incision into the cervix were closed with interrupted stitches 
of strong catgut. The uterine cavity was washed out with a 
warm saline douche. The incision in the anterior fornix was 
closed with sutures of medium catgut, and the perineum was 
repaired with a sub-cuticular stitch of medium catgut. A small 
gauze drain was put into the cervical canal. Gauze was also 
packed into the vagina after it had been douched with hot 

She was somewhat breathless for two days after the opera- 
tion. On the third day she was able to lie in the recumbent 
position. She went home on the 16th February feeling very 
well. She had no distressing breathless attack after the 
operation. On her dismissal she was still cyanosed, especially 
marked on her cheeks, ears, nose, and finger nails, and there 
were fresh small sub-conjunctional haemorrhages. 

It was evident from the extreme distress which this 
patient's cardiac condition occasioned, that the termination of 
her pregnancy was urgently indicated, and the only question to 


be considered was the method to be adopted. Her cardiac 
condition appeared critical, and it seemed evident that the 
more speedily the uterus could be emptied, the less would be 
the strain on the heart, therefore it was decided to perform 
vaginal Csesarean section. The result was very satisfactory. 

Case V. — Haemorrhage due to Premature Separation of 'part 
of a Low-Placed Placenta — Placenta Prwoia. — Mrs T., ret. 38, 
had been married sixteen years, and had six children, the last 
being born eighteen months before admission. She had a 
miscarriage at two and a half months, three years before 
admission. She was admitted on 7th June 1906, complaining 
of floodings. 

At the beginning of March, while still nursing her child, 
the milk ceased, and patient had a severe bleeding for a day 
and a night. She got up next day and felt quite well till five 
weeks later, when she had a second flooding. The bleeding 
came and went for a day or two, and she was confined to bed 
for a week. On getting up she felt weak and went for a 
holiday for a week, and on returning home she again had red 
discharge. The discharge came on every night for two weeks 
— not copious, only coming away when she lay down. At the 
end of two weeks another flooding took place, and for the four 
weeks previous to admission she had been confined to bed with 
a more or less constant red discharge. 

Before the present illness her menstrual history had shown 
nothing of a morbid nature. Her labours were natural, and 
she had no serious illness. 

On admission, a tumour was felt in the abdomen, suggesting 
a six and a half months' pregnancy. At parts the swelling 
was soft and doughy, and at others hard. There was greater 
resistance on the right side as a whole, and on this side harder, 
irregular masses were felt, suggestive of limbs. Foetal heart 
sounds were audible just below the umbilicus in the middle 

BY DR N. T. BREWIS. 199 

line. Per vaginam, a sense of doughiness of the lower uterine 
segment was felt. For a week she continued to pass clots, and 
on the eighth day after admission she had a profuse haemorrhage, 
accompanied by severe abdominal pains, having the character 
of labour pains. The patient was very weak and exhausted. 
In the evening of that day it was decided to deliver as rapidly 
as possible. It was found that the external os had dilated 
very slightly — only sufficiently to allow the tip of a finger to be 
introduced. Chloroform was given. 

The median basilic vein was exposed, and about a quart of 
saline given intravenously. The vagina was then well douched 
out, the cervix grasped by strong volsellae, and pulled down. 
An incision was made through the anterior vaginal wall 
transversely, and the bladder pushed up. A sound being 
passed into the bladder, an incision was made along the anterior 
surface of the cervix and continued beyond the internal os. 
The presenting part was seen as a bluish sac. The membranes 
were ruptured, and the liquor amnii allowed to escape. 

On introducing the fingers the placenta was felt to one 
side, low down, and the head of the child was presenting. The 
child was delivered by forceps. The hand was then introduced 
to remove the placenta, which was partially adherent. After 
expressing the placenta the interior of the uterus was douched 
with hot sterile water. The incisions in the uterus and vagina 
were closed by catgut sutures. She made a good recovery. 

This case was one of premature detachment of a portion of 
a low-placed placenta. Possibly at an earlier stage rupture of 
the membranes or slow dilatation followed by delivery might 
have been successful, but at the time that I operated the 
patient was in a highly critical state, and I felt that it was 
best for the patient to deliver as speedily as possible. I con- 
sidered her condition so dangerous that I transfused before the 
operation, a plan which I always practise in patients exhausted 
from loss of blood. 


The indications for vaginal section submitted by Diihrssen 
eleven years ago, were for conditions dangerous to the life of 
the mother or child, or both; abnormalities of the cervix and 
lower uterine segment, which make impossible or difficult a 
dilatation of the cervix by the uterine contractions ; and for 
dangerous conditions of the mother which may be removed 
by prompt emptying of the uterus, e.g., affections of the 
kidneys, heart, lungs. 

Whenever the element of time is important, vaginal 
Cesarean section is a great addition to our resources. An 
operation which enables the hand to pass with safety into the 
interior of the pregnant uterus in a couple of minutes' time is 
one which might have its indications extended to cases of a less 
serious nature, where the mother's life is not in peril, but 
where the operation can accomplish the desired end more easily 
and more conveniently than any other. Anyone who has had 
experience of this operation cannot do otherwise than commend 
it. An aseptic field, a clean-cut wound, an easy and rapid 
technique, the parts restored at the end of the operation to 
their original condition by a few catgut stitches, go to make 
an operation which must appeal strongly to anyone witli 
surgical instincts. 

The last case in which I followed Diihrssen's method was 
one in which the patient's life was not in danger. Her uterus 
might have been safely emptied by other means, but I pre- 
ferred vaginal Cesarean section, because it was as safe as any 
other, and was more easily performed. 

Case VI. — The patient was two and a half months 
pregnant, and haemorrhage had gone on continuously for five 

All the mothers recovered. 

A living seven and a half months' child was delivered in 

BY DR N. T. BREWIS. 201 

the eclamptic case, and a full-time child in the case of stenosis 
of the cervix. 

Br Lamond Laekie said he had no personal experience of 
the operation, but that during the last quarter at the Maternity 
Hospital he had had a case in which he had thought of doing 
vaginal Cesarean section. The case was one of eclampsia, the 
patient was comatose, and the prognosis was very bad. He 
had attempted to dilate the os with Hegar's bougies, and with 
Bossi's dilator, but had failed absolutely. The cervix was so 
rigid that he felt it would be wrong to persist in the attempt, 
and he desisted, with the view of performing vaginal Csesarean 
section later. Fortunately the patient began to improve, and 
by the following day no further interference was necessary. In 
three days there was practically no sign of eclampsia, the fits 
had ceased, the albumen disappeared, and five days after the 
attempted dilatation 'of the cervix, the patient aborted; the 
fact being that during the eclampsia the foetus died. Dr 
Brewis's paper was most interesting. There seemed to be so 
many possible conditions for which the operation might be 
done. He had noticed that Dr Brewis held that the operation 
was even indicated where the os might possibly be dilated, 
and the foetus delivered in that way. He supposed the opera- 
tion was more speedy than dilation of the os, when from 
twenty to thirty minutes were required, so that there was a 
distinct gain in that way. 

Br Haig Ferguson thanked Dr Brewis for his paper. He 
had had only one experience of vaginal Caesarean section, but 
had found the operation extremely satisfactory — so much so, 
that if again in similar conditions, he would prefer it to Bossi's 
dilator, which he considered to be extremely dangerous, and 
very seldom satisfactory. The patient was a primpara with 


eclampsia. She was about seven and a half months, had had 
twelve seizures, and was comatose ; the cervix was very rigid, 
no sign of dilatation, and the foetus alive. He determined to 
do vaginal Caesarean section, and followed the ordinary routine 
as performed by Diihrssen, and got the uterus dilated in a 
few minutes, and delivered the child (which presented by the 
breech) without any difficulty at all. He sewed up the lower 
segment and restored the parts to their former condition. 
Unfortunately the patient did not survive. She recovered 
consciousness, but again had a succession of eclamptic fits, 
and in spite of all treatment died the following evening. But 
he was so impressed with the ease with which the operation 
could be done, that in a case of eclampsia he should certainly 
prefer the operation to the use of Bossi's dilator. The only 
thing he should wish to criticise was in doing it in a woman 
who was only two and a half months pregnant. The simplicity 
of Diihrssen's operation was when the woman was near full 
time, and the lower uterine segment more fully developed. 
He could not see the reason why, in inducing an abortion one 
should have recourse to vaginal Caesarean section, for, un- 
doubtedly, there were certain risks; the incision might go so 
far up as to open the peritoneal cavity. He should prefer to 
induce abortion by dilators rather than risk the opening of the 
peritoneal cavity. The only other point was in regard to the 
indication in heart cases. He thought the best treatment 
was medicinal, and to avoid bringing on labour. He had found 
general treatment have, as a rule, satisfactory results. Cer- 
tainly in cases of eclampsia, and possibly in placenta praevia, 
where one knew the lower uterine segment and the cervix were 
extremely friable, a clean cut such as Diihrssen recommended 
— one that appealed to one's surgical principles, and one that 
would terminate pregnancy in a much more rapid and safe 
manner without setting up laceration, was much better. They 
were much indebted to Dr Brewis for having stepped into the 

BY DR N. T. BREWIS. 203 

breach and given them such an interesting paper. He thought 
that in the operation one needed to have plenty of skilled 
assistants, as it would be extremely difficult to do it if inade- 
quately assisted. 

The President agreed with the Fellows who had spoken, in 

thinking the subject a very interesting one. He was very 

glad Dr Brewis had come forward again with an obstetric 

paper, or one that was perhaps just on the border-line between 

obstetrics and gynaecology, for vaginal sections were more 

especially gynaecological. The indications for the operation 

had struck him as being extremely interesting from their variety 

— vomiting, eclampsia, stenosis of os, heart disease, placenta 

praevia. It seemed to him that one might generalise a little 

more, and say that cases in which the os was not taken up were 

specially suitable ones. In eclampsia, where the os was taken 

up the case might be amenable to other measures, but 

where it was not taken up there was great risk in using Bossi's 

dilator, which gave the risk of severe laceration. Formerly, 

the only operation consisted in numerous incisions into 

the cervix, which had seemed to him to tempt danger and 

possible disaster. But this localised clean cut did seem 

to meet the indication where the os was not taken up, 

and thus in cases which were not far on in pregnancy. 

He thought the reason why the operation was chosen in 

the heart case was that there was a condition of a systole, 

and that the case was not like many cases in which it would 

not matter if one waited for a while. In such a case as that 

cited, he considered one would be quite justified in doing the 

operation. He supposed that a knife, scissors, and catgut 

sutures were about all that was needed for the operation. He 

was sure he expressed the feelings of the Society in thanking 

Dr Brewis for coming forward at such short notice, and for 

giving them such an interesting paper. 

Dr Brewis thanked the President and Fellows for the very 


kind way in which they had received his paper, though it was 
somewhat obstetrical. He considered the cases related in the 
paper belonged to the gynaecology of obstetrics. He could not 
agree with those who thought the operation only suitable for 
hospital. The first case narrated was performed in a private 
house, without any special preparation, and with a few 
borrowed instruments. A pair of scissors, two volsellse or 
forceps, a small curved needle, and catgut are all the instru- 
ments that are specially needed. No doubt this, like all other 
operations, is best performed in hospital, but when the patient 
is not fit to be removed, there is no reason why she should not 
have the benefit of the operation in her own house. With 
regard to the opinion offered by Dr Haig Ferguson on the 
justifiableness of operation in the case of heart disease, Dr 
Brewis thought that if Dr Ferguson had seen the case he 
would not have* hesitated to recommend the operation. Dr 
Brewis considered that the operation saved the patient from a 
perilous position, and probably saved her life. Dr Brewis did 
not consider there was more danger in this than in any other 
obstetric operation, and on that account he would prefer it in 
some cases of abortion. In none of the cases had he found it 
necessary to make the posterior incision through the cervix. 


By B. P. Watson, M.D., F.R.C.S.E., University Gynaecological Tutor, 
Royal Infirmary, Edinburgh ; Gynaecologist to the Cowgate Dispen- 
sary, Edinburgh. 

Four years ago papers were read before this Society by Dr 
Angus Macdonald and Dr Fothergill, giving accounts of two 
cases in which after the administration of potassium chlorate to 
the mothers during pregnancy, children were born with enlarged 


thyroid glands. About the same time a paper appeared in the 
British Medical Journal, by Hewetson, in which he described 
the appearances of the much enlarged thyroid gland of a child 
born after the administration of potassium chlorate and potassium 
iodide to the mother. Cases following the administration of 
potassium chlorate had previously been recorded by Sir J. Y. 
Simpson in 1855, and Dr (now Sir) A. E. Simpson in 1866. 

Apart from these I know of no other cases in which hyper- 
trophy of the foetal thyroid, has followed, or been coincident 
with the administration of such drugs to the mother during 
pregnancy, and this is my reason for bringing the present case 
before the Society. 

The case has a further interest, in that it shows in a marked 
manner the action of potassium iodide in preventing intra- 
uterine death of the child in a case of maternal syphilis. 

The history is as follows : — 

Mrs C, age 27, came to me at the Cowgate Dispensary four 
years ago. Five years previously she had been married, and 
when pregnant with her first child had been infected with 
syphilis. The local manifestations of the disease were very 
pronounced, and a considerable amount of ulceration seems to 
have occurred. She carried the child to full time, but it died 
during delivery by forceps. As far as she knew, it presented 
no sign of disease. Her attendant at the confinement informed 
her of the nature of her disease, and after the birth of the child 
she had sore throat, her hair fell out, and a rash appeared on 
the body. 

Following in rapid succession after the birth of her first 
child she had a series of five miscarriages: the first at the 
seventh month, second at third month, third at seventh month, 
fourth at three and a half months, and fifth at seventh month. 
The seven-months' foetuses were all born in a macerated con- 
dition, and had evidently been dead in utero for periods varying 
from a week to a fortnight. The patient mentioned that after 


each miscarriage she was troubled with a sore throat, and that 
her hair fell out much more that usual. I had not previously 
heard patients with syphilis complain of this. It looked as if 
there were a fresh dose of the poison liberated as each ovum 
was cast off. I may say that the husband who infected her had 
never been treated. 

When I first saw her she was two months advanced in her 
seventh pregnancy and was extremely anxious to have a living 
child. She was given a mixture containing potassium iodide, 
aromatic spirit of ammonia, and infusion of gentian, and in- 
structed to take a dose containing 10 gr. of the iodide three 
times daily. She carried out the instructions faithfully, and 
took 30 gr. of iodide every day right up to the onset of labour. 
The course of the pregnancy was normal in every respect, and 
her child was born at full time, alive, well nourished, and 
apparently healthy. The placenta was large and flabby, with a 
few infarcts, but otherwise normal in appearance. In a week 
the child developed signs of syphilis, with a character- 
istic rash over the buttocks, and snuffles, and a week later it 
died. I had not an opportunity of making a post-mortem 

Four months later the patient again became pregnant, and 
from the second month onward she took 30 gr. of potassium 
iodide per diem. The pregnancy was going on normally up to 
the end of July 1905, when she had completed her seventh 
month: foetal movements were then strong and the heart 
audible. The Dispensary being closed in August, she was given 
what was thought to be sufficient medicine to last her over the 
month. It had, however, been finished about ten days before 
the end of the month, and during that time she had taken none. 
She came to see me on 3rd September, and said she had felt no 
movements for the past three or four days, and that she feared 
the child was dead. Ten days later she gave birth to a 
macerated foetus which had evidently been dead for about a 


fortnight. The placenta was large, and contained many large 

In February 1906 she again became pregnant, and the same 
line of treatment was followed throughout, viz., the adminstra- 
tion of 30 gr. of potassium iodide a day from the second month 
up to the time of labour. She carried her child to full time, 
had an easy labour, and made a satisfactory recovery. 

The child, a male, at birth weighed 6J lbs., and appeared in 
every way healthy, except that it had a large swelling in the 
neck in the region of the thyroid gland. The two lobes were 
equally enlarged, extending up the neck on each side of the 
trachea, and there was also considerable thickening of the 
isthmus. The swelling did not extend below the level of the 
manubrium sterni. There was very considerable embarrassment 
of respiration, inspiration being accompanied by loud stridor. 
The breathing was always more laboured when the child was 
laid on its back, or if the head became extended ; it would then 
become extremely cyanosed. It was unable to suckle, and had 
to be fed by spoon. For the first fortnight after birth there 
was no perceptible change in the goitre, but after that it beo-an 
to undergo a slow but progressive decrease in size with a 
corresponding diminution in the respiratory difficulty. From 
the fourth week the child began to show 'signs of congenital 
syphilis. For this, as well as for the obstinate constipation 
from which it suffered, it was treated with grey powder. When 
three months old there was well-marked cranio-tabes present. 
In spite of its obvious syphilitic condition the child throve 
fairly well up to the age of three and a half months, when it 
developed epidemic cerebro-spinal meningitis. It was sent to 
the Eoyal Hospital for Sick Children, under Dr John Thomson's 
care, where it died after being ill for ten days. Dr Stuart 
M'Donald performed the post-mortem, and to him I am in- 
debted for the following notes : — 

Thorax. — There is a large goitre present, which measures 


about 2\ inches across from side to side. It is compressing the 
trachea laterally, is firm and elastic in feeling, and on section 
looks like normal thyroid tissue. 

Heart. — Some dilatation of right side; no endocarditis; 
myocardium soft and flabby. 

Lungs. — Both congested and cedematous, with patches of 
lobular collapse and emphysema; there is extensive broncho- 
pneumonic consolidation of left lower lobe and of upper lobe on 
right side. The larger bronchi are congested ; bronchial glands 
not enlarged. 

Abdomen. — Spleen shows acute congestion, pale ; Malpighian 
bodies present. 

Ziver. — Cloudy and fatty. Marked inter-cellular cirrhosis. 

Bones. — Marrow of ribs red and lymphoid. Marked cranio- 
tabes present. 

Brain and Cord. — Acute leptomeningitis, basal and vertical. 
Convolutions flattened. Great dilatation of superficial vessels. 
Exudate most marked in sulci ; yellow in appearance, very like 
a pneumococcal case in appearance. 

Cord. — External pachymeningitis over lower part of cord; 
thick fibrinous-looking exudate present; there is diffuse lepto- 
meningitis of cord, exudate resembling that over brain. 

The two chief points of interest in the case are : — 

1st. The action of potassium iodide in preventing intra- 
uterine death ; and 

2nd. The enlargement of the thyroid gland of the last child 
after the administration of potassium iodide to the mother 
during pregnancy. 

(1) That the potassium iodide did have an influence in 
enabling the patient to carry her children to full time, and that 
this was not merely due to the gradual elimination of the 
syphilitic poison from her system with the lapse of time, is, I 
think, clearly shown by the history of the second pregnancy, 
during which she had the drug administered. In the first and 


third pregnancies under treatment she took 30 gr. of iodide 
daily, right up to the onset of labour, and in both cases full- 
time, living children were born. In the second pregnancy the 
stoppage of the drug for a fortnight at the eighth month was 
followed by the death of the child, and I think we are justified 
in concluding that the one was a direct result of the other. 

It is to be noted, however, that while potassium iodide 
seemed to enable the patient to have living children, it did not 
prevent the subsequent development of well-marked signs of 
congenital syphilis in these children. For this reason I shall, 
in future, in cases of a similar kind, combine mercury with 
potassium iodide, as is usually recommended. 

I gave potassium iodide alone in this case, as in a previous 
case of repeated miscarriage with no syphilitic history it had 
been successful, the patient having a full-time, living child, 
and I thought that it would be doubly efficacious in the present 
one. Lomer gives a record of twenty cases of habitual abortion 
due to syphilis, albuminuria, and endometritis, successfully 
treated by potassium iodide and iron. He supposes that the 
iodide acts by preventing placental haemorrhages, which so 
often precede the death of the foetus. Other observers have had 
good results in similar cases with potassium iodide. 

Potassium chlorate is the drug which, on the original recom- 
mendation of Sir J. Y. Simpson, is usually employed in non- 
syphilitic cases. Its mode of action is still in dispute ; the 
hypothesis that it parts with its oxygen to the foetal blood 
having been disproved. Fothergill believes that it acts by 
preventing excessive clotting in the intervillous spaces of the 

The apparently equally good results which follow the use of 
potassium iodide, even in definitely non-syphilitic cases, seem to 
suggest that it is the potassium which is the essential element, 
and that the particular salt employed does not so much matter. 
This possibility was mentioned by Dr Ballantyne in the discus- 



sion on Dr Fothergill's paper, and he was led to mention it 
from a knowledge of the fact that large quantities of potassium, 
together with lime and iron, pass to the foetus in the last three 
months of pregnancy. Both potassium iodide and potassium 
chlorate are readily diffusible salts, and quickly pass to the 
foetus after introduction into the circulation of the mother. In 
the present case I had the placenta examined for the presence 
of the salt, but none was found, owing probably to the compara- 
tively small dose the mother was taking and the rapidity of its 

It would serve no useful purpose to mention the various 
views that are held as to the mode of action of these salts in 
preventing intra-uterine death, and I only refer to the possi- 
bility of the potassium being the essential element in order to 
suggest that in similar cases it might be of interest to try the 
effect of some of its other salts, and note whether they were 
equally efficacious. 

(2) The occurrence of thyroid enlargement in the- last child. 
Congenital goitre is, under any circumstances, of comparatively 
rare occurrence, so that to find six cases following the adminis- 
tration of potassium salts to the mother during pregnancy, for 
the prevention of foetal death, seems more than coincidence. 
At the same time it is difficult to arrive at any adequate 
explanation of them. 

In the cases of Sir J. Y. Simpson, Sir A. E. Simpson, 
Macdonald and Fothergill, potassium chlorate was the drug 
used, in Hewetson's case potassium chlorate and potassium 
iodide, and in my own potassium iodide alone. 

In none of these six cases was there any history of goitre in 
the families, whereas in a large proportion of the other cases of 
congenital goitre reported one or both of the parents have been 
goitrous. Four of the six cases died shortly after birth as the 
result of tracheal compression; and in the two that survived — 
Sir A. E. Simpson's and my own — the thyroid underwent a 

Hypertrophy of Foetal Thyroid. 

[To f<u,t page 211 


progressive decrease in size from birth onwards — a phenomenon 
noted in most cases of true congenital goitre. 

In Fothergill's and Hewetson's cases, in which the child 
died shortly after birth, detailed reports are given of the histo- 
logical appearances of the glands. In the former there was a 
large quantity of glandular tissue of an adenomatous type, 
with many large blood-vessels in the connective tissue septa. 
In the latter the glandular tissue was not so abundant, being 
represented by a loose mesh-work of connective tissue, lined by 
round and flat cells in one or more layers, but the blood-vessels 
were very large and numerous, and Hewetson classifies it under 
the vascular or congestive type of goitre, which is the com- 
monest type in congenital cases. 

In neither case was there any colloid present in the acini. 
Although there is no histological report on Macdonald's case, 
the fact that there were variations in size within short intervals, 
apparently clue to intermittent congestion, probably indicates 
that it also belonged to the congestive variety, and from the 
description of Sir J. Y. Simpson's case it may also have been of 
this type. 

In the present case the enlargement of the thyroid is due 
to a general parenchymatous overgrowth of the gland. There 
is a large quantity of colloid present, the vesicles being widely 
distended with it, and a very little inter- vesicular substance is 
left. The cells lining the vesicles are low and compressed 
looking. In fact, the appearances are exactly those met with 
in parenchymatous goitres occurring in the adult (see Plate). 

It must be remembered that the present differs from 
Fothergill's and Hewetson's cases in that the child was nearly 
four months old at its death, whereas theirs were only a few 
hours old. In Hewetson's case, moreover, the child was a 
seven months one. Then, again, the present child died after 
an acute febrile disease lasting for twelve days. What the 
exact condition of the gland was at birth can only be a matter 


of speculation, but it can hardly have belonged to the vascular 
variety of goitre described by Hewetson, as the vessels in it 
are not at all numerous, and those present are not large or 
dilated. It is more likely that from the first it had been of 
the parenchymatous variety. 

Such are the facts regarding these cases, but when we try 
to arrive at an explanation of them we are met with many 

In the first place, it is not possible to say whether the 
enlarged thyroid glands of these children were functioning or 
not. The absence of colloid in Fothergill's and Hewetson's 
cases would lead us to suppose that the glands were function- 
less, for it is the colloid which contains the active principle. 
But in my own case the presence of colloid does not necessarily 
point to functional activity, for colloid may be present and yet 
contain no thyroidin, which is the active principle, and without 
which the colloid is said to be inert. J. W. Simpson, in a 
paper on " The Thyroid Gland in Eelation to Marasmus," 
recently published, points out that though colloid may be 
present in the thyroid glands of new-born children, and even 
premature infants, it may, on chemical examination, be found 
to contain no active principle ; and he believes that new-born 
and young infants have little or no efficient thyroid secretion. 
In none of these six cases, unfortunately, has any chemical 
examination of the gland been made, so that we cannot say 
whether the glands were functionally active or not. That is 
the first difficulty. 

Secondly, granting — which I think we must — that the 
hypertrophy of the foetal thyroid following drug treatment of 
the mother for repeated abortion in these cases was not a mere 
coincidence, two explanations are possible : first, that the hyper- 
trophy is due to the action of the drug given ; and second, that it 
is due to the condition of the mother's blood, which caused the 
abortions and necessitated the administration of the drugs. 


If Hewetson's and my own had been the only cases of the 
kind recorded, we should have been strongly tempted to have 
ascribed the thyroid hypertrophy to the administration of 
potassium iodide, which is known to have some action on the 
thyroid secretion by virtue of the iodine which it contains. 
But, in the other four cases, only potassium chlorate was given, 
and no iodide. This serves to show how careful we must be in 
jumping to conclusions. 

On the whole, I am inclined to think that the hypertrophy 
is just as likely to be due to the condition of the mother's 
blood as to the action of the drug given. Simpson points out 
that adults suffering from tuberculosis, alcoholism, and syphilis 
almost invariably have sclerosis of the thyroid gland, and that 
there is constantly a sclerosis in the gland of children of tuber- 
culous mothers. As he puts it, "unhealthy parentage may 
produce degenerative changes in the thyroid of the offspring/' 

It is possible that in this is to be found an explanation of 
such cases as the present one and those previously recorded. 

But in the present state of our knowledge of thyroid 
physiology, not to mention the diversity of opinion held re- 
garding the mode of action of such drugs as potassium iodide 
and potassium chlorate, we cannot arrive at any definite con- 
clusion as to their true etiology, and must meanwhile be con- 
tent with placing them on record. 


Ballantyne. — " Antenatal Pathology." Edinburgh, 1902. 
Fothergill.— Edin. Obst. Trans., 1903-1904, p. 41. 
Hewetson. — Brit. Med. Journ., 1903, vol. i., p. 657. 
Macdonald (Angus). — Edin. Obst. Trans., 1902-1903. 
Lomer. — Zeit.f. Geburt u. Gyn., lxvi., Hf. 2. 
Simpson (Sir A. K).~Glasgoiv Med. Journ., 1866, p. 181. 
Simpson (J. W.).~-~Scot. Med. and Surg. Journ., 1906. 
Simpson (Sir J. Y.).— Monthly Journ. of Med. Scien., 1855, p. 350. 


Dr Ritchie thought they might congratulate themselves on 
having had a most interesting paper, giving one more case in 
addition to many already recorded, of the advantage of potassium 
iodide in cases where death of foetus occurred in utero. 
Dr Watson suggested they might try whether other potassium 
salts might not be equally useful. He questioned whether 
one was quite justified in making such experiments, when one 
knew the great advantage of iodide of potassium as an almost 
unfailing certainty. He had listened with great interest to 
Dr "Watson's discussion as to the relation of the enlarged thyroid 
to the case, and he quite agreed that they could not come to 
any definite conclusion as to the precise relation. It seemed 
to be quite clear that debility, alcoholism, unhealthy conditions, 
were liable, in certain persons, to be followed by some peculiarity 
of the thyroid gland. 

Dr Oliphant Nicholson thought Dr Watson had contributed 
a very valuable paper to the Society, and yet it seemed that, if 
possible, he had made an obscure subject still more obscure. 
The thyroid gland seemed to have a special affinity for iodine, 
which was evidenced by the fact that there was a large quantity 
of iodine in the thyroids of animals which were getting 
potassium iodide given to them along with their ordinary food. 
Iodine was certainly an essential element in the internal 
secretion of the gland ; therefore the gland had to rely, in the 
ordinary way, upon the traces of iodine contained in the food. 
Thus when one gave potassium iodide to a person it might be 
assumed that the thyroid activity of that person was increased ; 
the gland would pick the additional iodine out of the blood, 
and elaborate it into iodothyrin. The remarkable therapeutic 
properties of iodide of potassium in so many widely different 
pathological conditions were difficult to explain, unless the 
drug acted, as had been suggested recently, by modifying the 
thyroid activity in some way. Thus iodide of potassium and 
thyroid extract were to a certain extent interchangeable 


remedies in certain diseases. Iodide of potassium was often 
given quite empirically, e.g., in very large doses to arrest the 
secretion of milk. This was a very precise way of arresting 
milk, and it seemed quite probable that the result was brought 
about by the iodide producing some alteration in the thyroid 
activity. When the thyroid gland became enlarged in a 
young person — a parenchymatous goitre —such a condition 
certainly occurred in the first instance as the result of a call 
by the tissues for an increased supply of thyroid secretion. 
He thought it allowable to assume that in the fcetus 
the same explanation held good — that for some reason the 
foetal thyroid was making an attempt to cope with increased 
work. Whether the extra secretion was called for to help the 
mother, or to meet some increased strain on its own metabolism, 
he could not say. The etiology of simple goitre was still very 
obscure ; when occurring in certain districts in endemic form, 
it was due to the presence of something in suspension in the 
drinking-water of the district. If the people living in that 
district drank rain-water, they did not develop goitres. It was 
not yet proved whether the substance in the water was organic 
or inorganic, but recently Major M'Carrison had shown that 
large doses of thymol caused ordinary simple goitres to greatly 
diminish in size, and sometimes to disappear. He suggested 
that the condition was of bacterial origin. When that point 
was ascertained, it might throw further light on the occurrence 
of goitre in the foetus. Dr Chalmers Watson had carried out 
some interesting experiments in feeding certain animals on an 
exclusive meat diet, which might throw some light on these 
cases of foetal thyroid hypertrophy. Such a dietary induced a 
very marked hypertrophy of the thyroid gland. If the 
explanation was that the hypertrophy of the gland resulted 
because such a diet contained no calcium salts, it was a matter 
of considerable interest. The enlargement of a foetal thyroid 
might be connected in some way with a diminished amount of 


calcium passing to it from the mother. During pregnancy it 
was known that the quantity of lime salts in the mother's 
tissues might vary very greatly from time to time. Dr Blair 
Bell had shown that the thyroid activity was closely related to 
the calcium exchange in the tissues. At present there were 
a great many isolated facts about the thyroid gland in relation 
to pregnancy and lactation, but it seemed impossible to correlate 
them and bring them into line — one fact seemed to be abso- 
lutely contradictory to another. Much more light was needed. 
He had always used potassium iodide throughout the course of 
pregnancy in cases where death of the foetus had occurred, and, 
in many cases, with very good results. Sometimes under this 
treatment a woman went to full term ; at all events, one was 
generally able to prolong the pregnancy till the child was of 
viable age. He had never seen an enlarged fcetal thyroid in 
these cases, because evidently the necessary factors for its 
production had not been present. Dr Watson had added an 
important contribution to a very interesting subject. 

Dr Keppie Paterson had listened with great interest to the 
paper, and also to the remarks of the other speakers. Dr 
Nicholson's statement that he had treated several cases all 
through pregnancy, but had not found any case of enlarged 
thyroid, was an important contribution in itself. Eeferring to 
his own experience, he had given up the use of iodide of 
potassium. In practice he had attended many women with 
syphilitic abortions. They could be placed in two classes. In 
some there were definite signs of an attack of syphilis, with 
rash, falling out of the hair, and all the usual signs — these 
cases were rare; in most cases there was simply a syphilitic 
dyscrasia, the patient becoming thinner and weaker, with 
perhaps falling out of the hair. This bad state of general 
health occurred during a pregnancy and continued after the 
abortion or pregnancy was over. He had at first treated 
these cases with iodide of potassium, and perchloride of 


mercury, but had very soon given up the use of the iodide, and 
for many years had only given the perchloride of mercury, and 
with very great benefit. Patients almost always fattened 
upon it, and one was then almost certain that they would carry 
to full time and bear a healthy child. How iodide of potassium 
or perchloride of mercury acted in the case of syphilis was 
probably due to some effect on the opsonins. He related an 
instructive case whom he had attended in a few pregnancies. 
She had two still-born children, and she came under his care 
during her third pregnancy, when he treated her with iodide of 
potassium and mercuric perchloride. This child was also still- 
born. He advised her to put herself under treatment when- 
ever she again passed a period ; this she did, and the treatment 
was efficacious, as she gave birth to a living child about full 
time, who has never shown any signs of congenital syphilis. 
At her next pregnancy she did not begin the medicine until 
about the fourth month, and this ended in a still-born child. 
Her next conception was treated very early, at the fifth or 
sixth week, with perchloride internally, and resulted in a 
healthy child. She was again careless at her next pregnancy, 
delaying the commencement of the drug, and it again ended in 
a still-birth. In most cases he gave -^ gr. of perchloride of 
mercury thrice daily, beginning early until after the fourth 
month, and then only twice daily. In many cases a course of 
mercury during one pregnancy was enough, and subsequent 
pregnancies ended in healthy children. In other cases where 
there was a bad dose of parasyphilis, and where probably the 
husbands had a bad form of syphilis, it was necessary to give 
treatment during each pregnancy. He had used the per- 
chloride in preference to any other form of mercury, as he had 
been taught in Vienna that in whatever form mercury was 
administered, even as inunction, it only did good because it 
was converted into the perchloride. 

Dr Haig Ferguson said that the woman seemed to get a 


fresh infection after each pregnancy. Dr Watson had mentioned 
that the husband had never been treated for syphilis. He 
had seen women treated for years for syphilis with iodide of 
potassium and mercury, but he had never seen a case of f oetal 
goitre in such cases, though he had seen occasionally goitrous 
children without any history of treatment by iodide of potassium. 
Dr Keppie Paterson had mentioned the treatment of pregnant 
women with mercury, and had spoken of the advantage of 
giving the per chloride. He, too, had found that mercury had 
a much better effect than giving iodide of potassium alone. 
The red iodide of mercury ^ gr. was the preparation he used, 
combined with iodide of potassium 5 gr., for the purpose of 
dissolving it ; this could be continued for long periods, and he 
had found it more satisfactory than the perchloride. He had 
had the same experience as Dr Paterson, in finding that 
patients taking the mercury became fatter and looked more 
healthy and better nourished than before. He added his thanks 
to Dr Watson for his suggestive paper. 

The President said there were really two points brought out 
by Dr Watson very interestingly. The first was, the advantage 
of medicines given to the mother during pregnancy in pre- 
venting abortion and premature labour in cases of syphilis. 
This case had shown the benefit of potassium salts, and although 
they did not know how potassium chlorate acted, clinical facts 
warranted its use. The second point, as to the relationship 
of the enlargement of the foetal thyroid to the condition of the 
mother and to the medicine given, was quite a separate thing, 
but exceedingly interesting. Personally he had the growing 
impression that there was some connection, though it seemed to 
be extraordinary. The fact that foetal goitre was rare in the 
children of non-goitrous parents must be kept in mind. Six 
cases seemed a small number to draw conclusions from ; still it 
was a very extraordinary coincidence, if it were simply a 
coincidence. There was the argument that iodide of potassium 


was often given and yet the child was born without any goitre. 
That raised the whole question of placental transmission. The 
problem of antenatal therapeutics was not so simple. Some 
looked on it as giving the drug to the mother and producing 
the effect on the child. But in giving the drug to the mother, 
it might alter in its chemistry in her stomach, it approached 
the uterus through the circulation, in which again it might be 
altered; it was almost certain, as demonstrated by modern 
research, that the placenta altered things that passed through 
it, and it was not simply a question of transudation. It then 
reached the foetus, and the foetus itself might have an effect on 
it. Antenatal therapeutics was by no means simply a question 
of forcing a drug into a patient's stomach in order to have 
a definite effect. Another point was, that there was no doubt 
that the placenta did sometimes allow substances to pass 
through it, and at another time it would block the same 
substance, either through some subtle, chemical, or physicial 
change in it or in the syncitium. He therefore did not think 
it right to exclude the possibility that the drug given to the 
mother might have some influence in producing enlargement of 
the thyroid, although not doing so in every case. Certainly 
every case should be recorded. A suggestion had been made 
two or three years ago that they should give mercury in these 
cases in the form of the oleate through the vagina, giving it 
topically. There were a great many much more favourable 
results when the drug was absorbed directly through the tissues, 
reaching the placenta and foetus more directly. 

Br B. P. Watson, in reply, thanked the Society for the kind 
way it had received the paper. There was really nothing he 
could add, in reply to the various speakers, to what had already 
been said in the paper. 


Meeting VIII.— July 10, 1907. 
Dr J. W. Ballantyne, President, in the Chair. 

I. The following gentleman was elected an Honorary Fellow 
of the Society: — Dr med. Seichu Kinoshita, Professor of 
Gynaecology and Obstetrics, of Imperial University, Tokio, 

II. Professor Kynoch showed — (a) cervical fibroid, weigh- 
ing 12 lbs. The patient, a nullipara, set. 48, had complained 
of pelvic discomfort for four years. Menstruation regular till 
two years before coming under observation ; since then it had 
been irregular. Her chief complaint was intermittent attacks 
of retention of urine. On examination, the cervix was found 
high up and pressed against the symphysis pubis. The pos- 
terior fornix was filled with a hard, fixed tumour, the upper 
border of which reached to about 2 inches below the umbilicus. 
The fundus of the uterus was felt as a knob-like projection 
above the pubes and in front of the cervical tumour. On 
opening the abdomen the main tumour was found to be retro- 
peritoneal. The posterior layer of peritoneum was opened, 
the tumour brought forward, and along with the slightly 
enlarged uterus was removed by supravaginal hysterectomy; 
the peritoneal opening being closed with a continuous suture. 

(b) Uterine fibroid, complicated with pregnancy at the 
fourth month, removed by hysterectomy. The patient, eet. 36, 
complained of pelvic discomfort and frequent micturition when 
about four months pregnant. On examination, the cervix was 
found directed to the front, and the fundus reached half-way to 
the umbilicus. Through the posterior fornix there was felt a 
hard movable tumour connected with the uterus, but much 
harder in consistence. Attempts to push the tumour past the 
sacral promontory and retain it there failed. As it was obvious 


that the fibroid tumour would cause absolute obstruction to the 
passage of a viable child, operation was decided on. As the 
tumour was fairly movable, and thought therefore to be pedun- 
culated, it was hoped that its removal without interference with 
the pregnant uterus could be carried out. After its removal, 
however, the bleeding from the uterine wound was so persistent 
that it was thought safer to complete the operation by supra- 
vaginal hysterectomy. Both patients made very satisfactory 

III. Dr Ballantyne showed a copy of an edition of the 
ByrtTi of Manhynde of nearly one hundred years later than a 
copy he had previously shown to the Society. 


By John A. C. Kynoch, M.B., F.RC.P., F.B.C.S. (Ed.), Professor of 
Obstetrics and Gynaecology, University of St Andrews. 

Since the opening of the Dundee Maternity Hospital seven 
years ago, there have been admitted forty-six cases of con- 
tracted pelvis, which have been treated as follows : — 

(1) Extraction (breech presentation) . . 1 

(2) Spontaneous delivery (two premature labours) 10 

(3) Forceps . . . . .9 

(4) Version . . . . .4 

(5) Craniotomy . . . . .2 

(6) Induction of premature labour followed by 

symphyseotomy . , . .1 

(7) Induction of labour . . . .9 

(8) Symphseotomy . . . .3 

(9) Cesarean section . . . .7 



In reporting the following five cases of Cesarean section 
performed for contracted pelvis, it is interesting to note that 
three of the patients belonged to Glasgow, where rickets is so 
prevalent, and consequently where so many cases of pelvic 
deformity are met with. 

The following are the notes of my cases : — 

Case I. — J. Y., aged 21, was delivered of her first child 
eighteen months before admission to hospital. She had been 
thirty hours in labour, when repeated attempts to effect 
delivery by forceps in Walcher's position failed. Version was 
then resorted to, and a still-born, slightly premature male child 
was delivered, there being great difficulty in getting the after- 
coming head through the pelvis. She presented herself at the 
Dundee Maternity Hospital on 6th December 1903, supposed 
to be about eight months pregnant. She was of feeble intelli- 
gence, and consequently could give no history relating to her 
pregnancy. The date of her last menstruation, and of foetal 
movements, could not be ascertained. She was of healthy 
appearance; lungs, heart, and kidneys normal. She showed 
obvious signs of rickety deformity. Her height was 4 ft. 4 in., 
and there was antero-posterior curvature of both tibiae, less 
marked in the bones of the fore-arm. The pelvic measure- 
ments were as follows : — 

Interspinous . . . .9 ins. 

Intercristal . . . 9 „ 

Diagonal conjugate . . 3f „ 

True conjugate estimated at about 3 ins. The pelvis was of the 
small, flat, rickety type. Judging from the height of the 
fundus, the date of pregnancy corresponded to about the end of 
the eighth month. 

Forceps and version having failed to deliver a living child 


in her previous pregnancy, the alternative methods of delivery 
were — 

(1) Induction of premature labour. 

(2) Craniotomy (in the event of forceps failing at full 


(3) Symphyseotomy. 

(4) Caesarean section. 

Craniotomy was at once excluded, for as Sangar has stated, 
" the medical practitioner who does craniotomy on the living 
child in a case in which the patient can be removed to a 
hospital in order to undergo Caesarean section, with preserva- 
tion of the child's life, has fallen behind the requirements of the 

The induction of premature labour would have been 
almost absolutely favourable for the mother, whilst for the 
child the chances would have been almost proportionally 
unfavourable, brought up as it would have been in the most 
unsanitary surroundings. With regard to symphyseotomy, the 
degree of pelvic contraction in this case was perfectly suitable 
for this me'thod of delivery. But its immediate mortality is 
not any lower than Caesarean section performed under the 
most favourable conditions. It permits of, but does not 
deliver the child, and it prevents the patient being sterilised, if 
this is deemed advisable. With the ever-improving results of 
the Caesarean operation, the indications for symphyseotomy 
will probably come to be narrowed down to cases where 
forceps in Walcher's position fail, instead of being a recognised 
method of delivery at a pre-arranged date. The conditions 
being favourable, in the interests of both mother and child, for 
Caesarean section, and as it was specially desirable in this case 
to prevent further pregnancies, I decided to let the patient go 
on to full time, and do the operation at a pre-arranged date. 
On the 2nd January, the patient having been prepared as for 


an ordinary abdominal section, and before the onset of labour, 
I performed Cesarean section after the method of Cameron. 
The child's back was directed to the left side, head presented, 
heart sounds distinct. The abdomen was opened in the usual 
way, the incision extending from an inch above the umbilicus 
to 2 inches above the symphysis pubis. The uterus having 
been fixed in a symmetrical position, it was surrounded by 
large flat sponges. A flat vulcanite pessary was placed in the 
middle line below the fundus, and pressed on, in order to permit 
of the uterus being opened with a minimum loss of blood. 
The membranes being exposed, the uterine incision was 
extended downwards, the membranes ruptured, and the child 
delivered head first, the placenta attached to the posterior 
uterine wall being easily detached. The uterus was then 
turned out of the abdomen, the edges of the incision everted, 
and the upper and lower angles compressed by an assistant. 
Eight deep and six superficial silk sutures were inserted into 
the uterine wound, the mucosa not being included. The 
Fallopian tubes were then tied in two places and divided. 
The uterus responded well to sponge pressure, and contracting 
satisfactorily, it was returned into the abdomen, and the 
abdominal incision closed by through and through silkworm 
gut sutures. The child, a female, weighing 6 lbs. 12 oz., was 
slightly asphyxiated, but soon responded to artificial respira- 
tion. With the exception of a rise of temperature to 101° on 
the second day, the after progress of the case was an absolutely 
satisfactory one. The child was put to the breast at the end 
of a week, and was nursed throughout the period of 

Case II. — Mrs G-., aged 21, primipara, came under my 
observation on the 16th February 1906. She stated that labour 
had been in progress for about twenty-four hours, and that the 
membranes ruptured soon after labour began. She was a very 


small woman, with marked curvature of the bones of the legs. 
Her general condition was satisfactory, and beyond a slight 
trace of albumen in the urine, the various systems were normal, 
pulse 84. Pelvic measurements : — 

Interspinous . . . 8J ins. 

Intercristal . . . . 8 „ 

Diagonal conjugate . . . 3 „ 

True conjugate under . . . 2| „ 

The child's back was directed to the right side, head movable 
above the brim in the transverse diameter, and the os half 
fully dilated. Cesarean section being decided on, the operation 
was performed as in the previous case. The placenta was 
attached to the anterior uterine wall. The child — female — 
mature, weighing 6 lbs., was nursed during convalescence, and 
both left hospital well, three weeks after operation. It was 
ascertained later, however, that the child had died when two 
months old. 

Case III. — Mrs C, aged 26, ii.-para, was admitted to the 
Maternity Hospital on 24th January 1906, at the eighth month 
of pregnancy. The history given by her doctor was that she 
was delivered of her first child in September 1904. She had 
been long in labour before sending for assistance. Attempts 
to deliver with forceps having failed, craniotomy was resorted 
to, and with great difficulty the child was pulled through the 
contracted pelvis. She was sent to hospital as a case suitable 
for Cesarean section. She was of healthy appearance, her 
height was 4 feet 6 inches. She had a wabbling gait, and there 
was slight curvature of the bones of both legs. The pelvic 
measurements were as follows : — 

Interspinous . . . 7f ins. 

Intercristal .... 8-J- „ 

Diagonal conjugate . . 3 J „ 

True conjugate . . . . 2| „ 


It was decided to keep her in hospital till full time, and to 
operate at a pre-arranged day and hour. 

At 10 A.M., on 21st February, and before the onset of labour, 
Csesarean section was performed, the steps of the operation 
being the same as in the previous cases. After the removal of 
the placenta and membranes I passed my finger into the cervix 
from above, in order to be satisfied as to the patency of its 
canal. This I found to be very considerably stenosed, as a 
consequence probably of injuries received during the mani- 
pulations necessary to effect delivery at the first confinement. 
I then passed a uterine sound through the cervix and closed 
the uterine wound. At first there was pretty copious bleeding 
through the cervical canal, but with the application of continuous 
sponge-pressure the uterus contracted satisfactorily. Both 
tubes were ligatured and divided. Ergo tin was given hypoder- 
mically immediately before and after operation. The child, a 
male, weighed 6J lbs., and left the hospital well. 

The patient's condition remained satisfactory during the 
first forty-eight hours after operation. After this she got 
restless. Pulse became quicker, and she died on the evening 
of the fourth day with all the signs and symptoms of septic 
peritonitis. At the post-mortem all the uterine sutures were 
intact, but the upper two had become infected, as shown by the 
presence of pus in their track. 

Case IV. — Mrs N sl primipara, aged 31, was admitted to the 
Maternity Hospital at midnight on 27th December 1906, 
having been in labour for seven hours. Except for chronic 
dyspepsia her previous health had been good, and the examina- 
tion of the various systems (beyond a trace of albumen in the 
urine) presented nothing abnormal. Temperature normal, pulse 
76, and general condition satisfactory. On pelvic examination, 
the cervix was found dilated to the size of a five-shilling piece, 
membranes ruptured, and the head was lying above the pelvic 


brim in the transverse diameter. The pelvic measurements 
were as follows : — 

Inter spinous . . . .9 ins. 

Intercristal . . . 10 „ 

Diagonal conjugate . . 3J „ 

True conjugate . . . 2f „ 

Cesarean section was performed as in the previous cases. The 
child weighed 6 lbs., and measured 20 inches. On 31st 
January the urine was free from albumen. Both mother and 
child progressed favourably, and left the hospital on 5th 

Case V. — E. M., primipara, aged 22, was admitted to 
hospital in labour on 23rd February 1907. She was of healthy 
appearance, her height was 4 feet 3 inches, and there was well- 
marked lumbar lordosis and curvature of both tibiae. Examina- 
tion of the various systems presented nothing abnormal. The os 
was dilated to the size of a half-crown piece, and the membranes 
were unruptured. The pelvic measurements were as follows : — 

Interspinous . . . .8 ins. 

Intercristal . . . 9 „ 

Diagonal conjugate . . 3 J „ 

True conjugate . . . . 2f „ 

Cesarean section was performed as in previous cases. The 
child (male) weighed 6 lbs. 12 oz., and measured 19 inches. 

Both mother and child made satisfactory recoveries, and 
left the hospital on 5th April. 

There are a few points connected with this operation which 
the experience of these cases suggests. First, a comparison of 
the methods of treating the uterus after delivery of the child, 


and these are — (a) Hysterectomy (partial or complete); (b) 
Retention of the uterus, with sterilisation, either by division or 
resection of the tubes ; (c) Leaving the uterus without sterilisa- 
tion, the true conservative operation. Each method has its 
advocates. With regard to the ethics of sterilisation there are 
two conflicting opinions. On the one hand, we have authorities 
who think that the question is one for the patient to decide ; on 
the other hand, there are those who hold that the operator 
should restore the patient to as normal a condition as possible, 
omitting any method of sterilisation, and repeating the operation 
of Cesarean section if occasion should arise. The first case 
which I have reported is one where it would have been unwise 
to leave the decision to the patient, as her intelligence was so 
feeble as to prevent her being able to look after herself properly, 
far less a family. The second case, however, where the patient 
was sterilised at the time of operation and where the child died 
when two months old, would favour the proposal that sterilisa- 
tion might with advantage be deferred until a second child had 
been delivered by Cesarean section. Granted that the patient 
is intelligent enough to understand the situation, and that she 
is willing to undertake the risk of a second operation, then 
sterilisation may be omitted at the first operation. Many cases 
are now reported where the operation has been repeated success- 
fully two, three, and four times on the same patient. Yet I 
hold that it is not justifiable to endeavour to break the record 
of the well-known case of Frau Eittgen, whose pluck in sub- 
mitting to Csesarean section five times led to a fatal termination 
at the fifth repetition of the operation. In all the cases I have 
reported the patients were sterilised by ligature and division of 
the tubes. This I consider a reliable enough method, and safer 
to the patient than hysterectomy, which 1 think should be 
restricted to cases of atony and suspected infection of the 
uterus. Another question which suggests itself is, What is the 
best time to operate ? In three of my cases labour had already 


commenced, and in two the operation was performed at a pre- 
arranged date, and before the onset of labour. Those who 
recommend waiting till labour has begun, do so because they 
think there is less chance of haemorrhage from uterine atony, 
and that a dilated condition of the cervix ensures freer escape 
of the lochial discharge. The first fear is groundless, for the 
uterus contracts quite as well before as after the onset of 
labour. That a dilated condition of the cervical canal is of the 
greatest importance, is shown by my unsuccessful case. Here 
the cervical canal was so stenosed as only to admit a uterine 
sound, and although this appeared to be sufficient to permit of 
escape of the lochial discharge, as shown by the occurrence of 
pretty free bleeding after the operation, yet I feel convinced 
that if dilatation of the cervix up to the size of a two-shilling 
piece had preceded Caesarean section, the case would have run 
as favourable a course as the others. In my first two cases I 
incised the uterine wall between the bars of a flat vulcanite 
pessary, as recommended by Cameron, to diminish the haemor- 
rhage during the uterine incision ; but I discarded it in my other 
cases, and did not find any marked difference in the amount of 
bleeding as a result. Further, haemorrhage during the operation 
I have found to be best controlled by an assistant grasping the 
broad ligaments, and subsequently maintaining uterine con- 
traction by sponge-pressure. In all my cases the uterine 
incision was a vertical one, and so far as I am aware the trans- 
verse incision of Fritsch does not seem to have proved itself in 
any way superior. Lastly, with sterilised towels well packed 
round the uterus, it is not necessary to adopt Muller's suggestion 
of -eventrating the uterus before opening it, as this involves a 
very large abdominal incision. But after the uterus has been 
emptied of its contents, and as a consequence diminished in 
bulk, the introduction of the uterine sutures is facilitated by 
bringing the uterus outside the abdomen. 


Br Barbour said they were very much indebted to Professor 
Kynoch for the extremely interesting paper, and congratulated 
him very heartily on the success of his cases. In Edinburgh 
they had not so many cases of contracted pelvis, and there- 
fore their experience in the Maternity Hospital here was 
limited. He quite agreed with Professor Kynoch in all the 
points he had raised. He thought he was right in saying that 
the best time for operation was before labour was begun. He 
thought he was also right as to the sterilisation of the patient. 
Unless the patient herself was very anxious to undergo the 
operation a second time, he thought they ought to do the best 
thing for the mother ; and as there was a certain risk in the 
operation of Cesarean section, and if they secured the one 
living child, they had done all they were justified in aiming at. 
With regard to the question of the cause of death in the case 
that had died. It was an interesting case. He was not quite 
clear that the infection had started from the uterine cavity — 
the sutures had not been passed through the mucosa. In all 
the cases mentioned, the average amount of the contraction 
seemed to be about 2 j inches. He thought Professor Kynoch 
was also right in declaring in favour of Cesarean section rather 
than symphyseotomy. He had not had any experience of 
symphyseotomy, but in one case of pubotomy the convalescence 
had been very protracted. Caesarean section was undoubtedly 
the preferable operation. He was also interested to hear that 
the patients were able to nurse their children. 

Dr Munro Kerr had been specially interested in this report 
of cases of Cesarean section, because they had so many of 
them in the Glasgow Maternity Hospital. It was specially 
interesting that three of the cases were from Glasgow. Professor 
Kynoch had raised a number of interesting points. He would 
be pardoned if he spoke for rather longer than usual on one 
or two of the points, for he was now speaking from an experi- 
ence of fifty-four cases of the operation. First, as to the time 


of the operation. He had not found it had made much differ- 
ence whether the operation was performed during or before 
labour. In primiparse there had sometimes been difficulty and 
discomfort from after-pains, which looked as if the patients 
had been suffering from retention of the lochial discharge. So 
much had these cases impressed him that in primiparse now he 
waited, if possible, till labour had commenced. In multipara 
he always arranged to operate before labour had begun. From 
his experience he would say that Professor Kynoch was quite 
right in saying that after emptying the uterus before labour 
commenced there was seldom any bleeding, and in only one of 
his cases had there been excessive bleeding that could not be 
controlled, and which had necessitated the removal of the 
uterus. This case had been brought from the country, some 
seventeen miles, and had been in labour some hours before she 
started her journey. She was considerably exhausted by the 
journey and by continuous uterine contractions. In all his 
other cases there had been no post-partum haemorrhage; the 
uterus had contracted well. With regard to the abdominal 
incision, Professor Kynoch had described what used to be the 
custom — making the incision from about an inch above the 
umbilicus down to within about an inch of the symphysis. 
He thought this was a mistake, and most modern operators 
made the incision as high as possible, so as to cut into the upper 
part of the uterus and avoid any approach to the lower uterine 
segment. With the old incision, in extracting the child, if the 
incision was not quite large enough, one might get a nasty tear 
of the lower uterine segment. Consequently there was great 
advantage in opening the uterus high. Further, with the 
high wound there was better union and less chance of hernia. 
With regard to the delivery of the child, Professor Kynoch had 
mentioned delivery by the head first, but Dr Munro Kerr 
had found it much easier to seize the legs and extract by the 
legs. A rather important point was the turning out of the 


uterus before opeuing it, or openiug it as it lay in the abdominal 
cavity. He thought what Professor Kynoch had said as to 
packing round with towels prevented the necessity of turning 
it out at all. If it were turned out, a larger abdominal 
incision was necessary. The only cases in which he thought it 
was advisable to turn out the uterus were those cases where 
the membranes had ruptured some time before. In such cases 
it was a distinct advantage to turn it out and pack round with 
sterilised towels, and open. In some of these cases he had 
actually not removed the placenta through the uterus, but had 
pushed it out through the vagina, and as far as possible swept 
everything downwards. In opening the uterus, he had quite 
given up the pessary. It was really quite unnecessary. It 
was of no value where the placenta was attached anteriorly. 
It certainly did slightly control the bleeding when the placenta 
was attached posteriorly, but was not in the least necessary. 
All other writers, in recent years, on Cesarean section, were of 
the same opinion. As to the question of sterilisation, it was 
very difficult to express an opinion. The ethical question was 
a very subtle one, and he was not prepared to take up any 
position regarding it. In a sense, as medical men they were not 
concerned with anything but doing the best for the patient. 
They were not concerned with future pregnancies ; that was for 
her husband and herself to decide. He thought there was a 
good deal to be said for those who took up the rational position, 
and said a woman should not be sterilised. Still, on the other 
hand, as an ordinary human being, he felt sorry for a woman 
who had to have her abdomen opened several times. There 
was no doubt that, if she went on having her abdomen opened 
time after time, she would die from the operation ; that is to 
say, her chances of dying were increasing each time. It was 
not correct to say that one could open the abdomen repeatedly 
without opening the peritoneal cavity, because it was shut off 
by adhesions. In five or six such cases he had had, in only one 


case was the peritoneal cavity completely shut off, and he was 
able to open into the uterus extra -peritoneally. In the other 
cases it had been quite impossible to open the uterus without 
opening into the peritoneum. In this connection he would 
mention two patients who had come to him after being 
sterilised by having their tubes tied and cut, who had each of 
them lost their children. In the first case he had said that 
nothing could be done, that there was no further chance of 
her becoming pregnant. In the second case he was prepared 
to resect the ends of the tied tubes, and try to make a 
permanent passage again between the uterus and the ovary. 
He had not said this on the off-chance of it being successful, 
but because he had seen two cases where the abdomen had been 
opened subsequently to Cesarean section in which the tubes 
had been tied, and the tubes were found quite patent. The 
silk had cut through the tubes, and in both of these cases it 
would have been possible to have joined together the ends of 
the tubes, with a great probability of establishing a permanent 
passage between the uterus and the ovary again. That was his 
only reason for sterilising by tying the tubes, and not by 
removing the uterus. He did not agree with Professor Kynoch 
that it was a safer operation to leave the uterus behind ; he 
thought that the safest operation and the one that gave the 
best results was that of removing the uterus. In taking away 
the uterus, all the dangers of the puerperium were removed, 
and the operation was not a difficult one, especially if the 
woman was not in labour, and the cervical canal had not 
become dilated. If the patient were in labour, and the canal 
become dilated, there was a large stump to stitch up and close, 
and the operation was then a little more complicated. As 
regards the position of Caesarean section and symphyseotomy, 
he entirely agreed with Dr Kynoch and Dr Barbour that 
Caesarean section was preferable, and" he thought Professor 
Kynoch had put the position of symphyseotomy in exactly the 


right way, namely, that it should be reserved for these cases 
where one just failed to deliver with forceps. The amount of 
pelvic contraction should be carefully estimated, and then 
forceps should be tried, and if one found one wanted a little 
more room, then symphyseotomy might be done. He had had 
nine cases of symphyseotomy, and had never seen any trouble 
afterwards in locomotion, and all the children had been 
delivered alive; and only one of his patients had had a bad 
urethral tear (a primipara) ; the others had made a satisfactory 
recovery. He believed the reason was that he had chosen 
these cases with very great care. As to his results from 
Csesarean section, the maternal mortality in fifty-four cases 
was 5 9 per cent. The foetal mortality — one child had died, 
and a second had died in hospital — giving an early and late 
mortality of 2 out of 54, or 3*7 per cent. 

Dr Lamond Lackie said his experience of the operation was 
limited, for though he had assisted several times at the operation 
he had had only one case of his own. For that he was indebted 
to Dr Haultain, who during his last term of duty at the 
Maternity Hospital allowed Dr Lackie to do the operation. 
The indication was deformed pelvis, and the conservative 
operation was performed. On the following day the patient 
had acute pneumonia, and was dangerously ill for a week. The 
abdominal wound became septic, and this took months to heal, 
but now the patient was well. Dr Lackie agreed with what 
had been said about sterilising the patient ; in the majority of 
cases it was desirable. He had listened with great interest to 
the record of Professor Kynoch's series of cases. 

Dr Ritchie asked what sutures had been used. 

Dr Kynoch replied that he had used silk. 

Dr Munro Kerr used catgut — size 1 or 2 ; at first, catgut 
sterilised by Jellett's method — later, Van Horn's. 

The President wished to refer to one or two points. As to 
closing the incision, long ago they used to have successful cases 


with no closure of the uterine incision at all. He remembered, 
some years ago, that a writer from Italy sent to him for details 
of the operation as performed here, and one of the questions 
was as to whether the incision was closed here. He said it 
had been a common thing not to close the incision with them, 
and the patients had made a good recovery. He had intended 
to have dwelt a little on the legal aspect of sterilisation, but as 
Professor Kynoch had to leave to catch a train, he would not 
now speak upon it. 

Professor Kynoch, in reply, said he was very much obliged 
to the Fellows who had spoken. He did not read the paper 
thinking that he had in so few cases anything original to say, 
but because of the opportunity of raising some questions in 
connection with the operation. There was one point to which he 
would refer regarding his unsuccessful case. Dr Barbour had 
asked if his sutures had included the lining membrane of the 
uterus. They had not done so, and it was a question whether 
the retention of the lochial discharge or infection of the suture 
employed was the cause of the sepsis. That would be a point 
which would be greatly in favour of sterilisation by means of 
hysterectomy. At the same time, Dr Kerr, with his large 
experience, insisted upon a certain amount of dilatation of the 
cervix, so that this must be a point of great importance in 
the success of the operation. 

[the "bykth of mankynde.' 



(Its Contents.) 

By J. W. Ballantyne, M.D., F.R.C.P. (Edin.), F.R.S. (Edin.), Lecturer 
on Midwifery and Diseases of Women, Surgeons' Hall and Medical 
College for Women, Edinburgh ; Physician to the Royal Maternity 
Hospital, Edinburgh j and President of the Edinburgh Obstetrical 

I have already x dealt with the author and the editions of the 
remarkable book known as the Byrth of Mankynde ; and I now 
intend to complete the consideration of the subject by 
discussing the contents of the work and the light thus thrown 
upon sixteenth century midwifery. Before I do so, how- 
ever, let me remind the reader that Eaynalde's Byrth of 
Mankynde is really a composite work, for it contains an English 
translation (by Eichard Jonas) of Eosslin's Be Partu Hominis, 
along with new matter added by Thomas Eaynalde. It has, 
therefore, three component parts : Eosslin's Be Partu Hominis 
as translated by Jonas, his additions thereto, and those which 
came from the pen of Eaynalde. In such a late edition as that 
of 1654, a fourth element is found in the supplementary 
matter added by a seventeenth century editor whose name we 
do not know ; but it is small in amount, consisting chiefly of 
directions for the nursing of children, and no further reference 
will be made to it. 

For purposes of description I might have taken any one of 
the first four Eaynalde editions (those of 1545, 1552, 1560, 
and 1565), for it is probable that they all appeared during the 
lifetime of Eaynalde; 2 but I have chosen that of 1560, 

1 Edin. Obstet. Trans., vol. xxxi., pp. 232-270, 1905-06. 

2 Raynalde is not likely to have been alive when the 1598 edition 


for it represents what was practically the final recension of the 
work, and does not differ (save only in spelling and minor 
details) from so late an' edition as that of 1654. The quotations 
which occur throughout this article are, therefore, to be regarded 
as taken from the 1560 edition except when it is otherwise 
stated. At the same time, I shall now and again refer to 
differences existing between the various editions, which may 
appear to have an interest other than the merely typographical 
and orthographical; and I shall draw attention to the very 
marked differences which are revealed by a collation of Jonas's 
edition of 1540 with those edited by Eaynalde from 1545 
onwards. Further, when I reach, in the description, the part 
of the book which is a translation of Eosslin's Be Partu 
Hominis, I shall devote some space to the consideration of 
this German obstetrician's life and work. 

The contents of Eaynalde's Byrth of Mankynde, it need 
hardly be said, have a special interest for obstetricians. The 
book stands, so to say, between the old and the new in 
obstetrics : empiric midwifery was, in 1540, beginning to give 
way before the advance of scientific obstetrics, although many 
years had still to pass before the knowledge of the anatomy 
and physiology of labour and the principles of anaesthesia and 
asepsis were to sweep away the practices begotten of ignorance 
and superstition. The year 1550, in which Pare introduced 
podalic version into obstetric practice, has usually been regarded 
as marking the separation between the midwifery of the past 
and that of the present ; if this be so, then Eaynalde's Byrth of 
Mankynde appeared at the very time when the great transition 
from the empiric methods of the ancients to the scientific 
procedures of the moderns was being brought about. It cannot 
fail to be a matter of the most intense interest to know what 
were the practices and principles of midwifery in England in 
the middle of the sixteenth century, and we find them both 
revealed to us in Eaynalde's book. 


The Preliminary Matter. 

The preliminary matter in a typical Kaynalde edition of 
the Byrth of Mankynde (such as that of 1560) consists of the 
title page, the Aristarchus preface, and the table of contents. 
In the single Jonas edition of 1540 there is the title page, the 
religious admonition, the dedication to Queen Catherine, the 
table of contents, and a table of weights and measures. 

The Title Page differs little, so far as wording is concerned, 
in the various editions prior to that of 1654. That of the 1560 
edition reads as follows : — " The Byrth of || mankynde, other- 
wyse na || med the womans || Booke. || Newly set foorth, corrected 
and || augmented: whose contentes ye || may reade in the Table 
of the || Booke, and most playne || ly in the Pro || logue. || By 
Thomas Kaynalde || Physition || 1560." The titles of the 1545 
and 1552 editions are similar, and no alteration of note 
appears until 1598, when the title reads: "The birth of 
man || kinde, otherwyse || named the Wo || mans Booke. || Set 
foorth in English by Tho || mas Eaynalde Phisition, and || by 
him corrected, and aug || mented. Whose con || tents yee may 
reade || in the Table fo || lowyng: || but most playnely in || the 
prologue." One or two slight differences are to be noted in 
the editions of 1604, 1613, 1626, and 1634, and then there 
occurs the radical change of the 1654 edition (see Plate XIV. 
in my previous article, loc. eit., p. 266). 

The wording of the title page of the Jonas edition is, as 
might be expected, somewhat different : " The Byrth of Man- 
kynde, newly translated out of Laten into Englyssha In the 
which is entreated of all suche thynges the which chaunce to 
women in theyre labor, and all suche inf yrmities whiche happen 
unto the Infantes after they be delyuered. And also at the 
latter ende or in the thyrde or last boke is entreated of the 
Conception of mankynde, and howe manye wayes it may be 
letted or furtheryd, with diuers other fruytefull thynges, as 


doth appere in the table before the booke. Cum privilegio 
Kegali, ad imprimendum solum." 

The ornamental border of the title page differs greatly in 
the different editions which were published before that of 1654, 
in which it entirely disappears ; but with this matter I have 
already dealt fully in my first article (loc. cit.). 

The reverse side of the title page contains (in the 1560 
edition) a short Preface, in English, commending the work in 
modest terms to midwives and matrons. The same preface 
appears in Latin in the 1545 and 1552 editions, and in English 
in all the others, but it is not always printed on the reverse 
side of the title page. I have reproduced it in Plates II. and 
XIII. of my former article, both in its Latin and in its English 
form. Since it begins "Albeit some Aristarchus," I have 
named it the Aristarchus Preface. 

The Aristarchus Preface is absent from the Jonas edition 
of 1540 ; but, occupying the corresponding position, there is a 
religious admonition which reads as follows (in ordinary 
English) : " Unto the Header. An admonition to the reader. 
For so much as we have enterprised the interpretation of this 
present book, offering and dedicating it unto our most gracious 
and virtuous Queen Katherine only, by it minding and tending 
the utility and wealth of all women, as touching the great 
peril and dangers which most commonly oppresseth them in 
their painful labours, I require all such men in the name of 
God, which at any time shall chance to have this book, that 
they use it godly and only to the profit of their neighbours, 
utterly eschewing all ribald and unseemly communications of 
any things contained in the same, as they will answer before 
God, which, as witnesseth Christ, will require a count of all 
their words, and much more then of all ribald and uncharitable 
words. Everything, as saith Solomon, hath his time, and 
truly that is far out of time, yea and far from all good 
honesty, that some use at the common tables and without any 


difference before all companies, rudely and loudly to talk of 
such tilings, in the which they ought rather to know much and 
say little, but only where it may do good, magnifying the 
mighty God of nature in all his works, compassionating and 
pitying our even-Christians, 1 the women which sustain and 
endure for the time so great dolor and pain for the birth of 
mankind and deliverance of the same into the world. Praise 
God in all His works." 

The rest of the preliminary matter of such an edition as 
that of 1560 consists of the Table of Contents, as we should 
now call it, or, as it is here termed, simply the Table. I have 
collated the Contents of the 1545, 1552, 1560, and 1654 
editions, and I find them to be almost identical, except, of 
course, with regard to the spelling, type, and pagination. 
There are, however, one or two small divergences ; thus, in the 
editions of 1545 and 1654 there is a heading in the third book 
(" Kemedy for the Cramp, or distention of members ") which 
does not appear in the other two editions referred to, but the 
presence of the heading does not indicate the addition of new 
matter in the text; again, in the 1545 and 1552 editions, eleven 
Anatomical Figures are named, and nine only in the 1560 and 
1654 editions. In the 1560 edition (in my copy at least) the 
" byrthe fygures" (seventeen in number or eighteen, if the 
" stoole " be counted) follow after the Table of Contents ; but in 
several of the other editions they are inserted at the end of the 
fourth chapter of the Second Book, their proper place according 
to the modern rules of binding. 

Before we reach the Table of Contents of the Jonas edition 
of 1540, we find additional preliminary matter consisting of the 
Dedication. It is so interesting that I reproduce it here in 
full. Some parts of it, it may be added, reappear in the 
Prologue to the Women Keaders which is peculiar to the 
Kaynalde editions. In ordinary English it reads as follows : — 
1 Even-Christen or even-Christian meant fellow-Christian. 


"Unto the Queen. Unto the most Gracious, and in all 
goodness most excellent virtuous Lady Queen Katherine, wife 
and most dearly beloved spouse unto the most mighty sapient 
Christian Prince King Henry the VIII. Eichard Jonas wisheth 
perpetual joy and felicity. Whereas of late (most excellent 
and virtuous Queen) many goodly and proper treatises, as well 
concerning holy scriptures, wherein is contained the only 
comfort and consolation of all godly people : as other profane 
arts and sciences right necessary to be known and had in use, 
have been by the painful diligence of such clerks which have 
embusied them in the same very earnestly and circumspectly 
set forth in this our vulgar English tongue, to the great 
enriching of our mother language, and also the great utility and 
profit of all people using the same, and among all other things, 
out of the noble science of Physick, have been divers proper 
and profitable matters compiled and translated from the Latin 
tongue into English, by the reading of the which right many 
have confessed themselves to have received great light and 
knowledge of such things, in the which they have found no 
small comfort and profit. And in this behalf there is in the 
Latin speech a book entitled Be Partu Hominis : that is to say, 
of the birth of mankind, compiled by a famous doctor in 
Physick, called Eucharius, the which he wrote in his own mother 
tongue, that is, being a German, in the German speech, 
afterward by another honest clerk at the request and desire of 
his friend transposed into Latin: the which book for the 
singular utility and profit which ensueth unto all such as read 
it, and most specially unto all women (for whose only cause it 
was written) hath been in the Dutch and French speech set 
forth and imprinted in great number, so that there be few 
matrons and women in those parts but (if they can read) will 
have this book always in readiness: considering then that the 
same commodity and profit which they in their regions do obtain 
by enjoying of this little book in their maternal language, might 



also ensue unto all women in this noble realm of England, I 
have done my simple endeavour for the love of all womanhood, 
and chiefly for the most bound service which I owe unto your 
most gracious highness to translate the same into our tongue. 
Most humbly desiring first your grace's highness, and then 
consequently all noble ladies and gentlewomen with other 
honest matrons to accept my pains and goodwill employed in 
the same : the which thing as I do not doubt for the wont 
and incomparable benignity goodness and gentleness inset and 
planted in your grace's nature, so shall it be no little encourag- 
ing unto me hereafter with farther deliberation and pains to 
revise and oversee the same again, and with much more 
diligence to set it forth. For considering the manifold daily 
and imminent dangers and perils, the which all manner of 
women or what estate or degree they be in their labour do 
sustain and abide : yea many times with peril of their life, of 
the which there be so many examples needless here to be 
rehearsed. I thought it should be a very charitable and laud- 
able deed, yea and thankfully to be accepted of all honourable 
and honest matrons if this little treatise so fruitful and 
profitable for the same purpose were made English, so that by 
that means it might be read and understanded of them all, for as 
touching midwives, as there be many of them right expert, 
diligent, wise, circumspect, and tender about such business, 
so there be again many more full undiscrete, unreasonable and 
far to seek in such things the which should chiefly help and 
succour the good women in their most painful labour .and 
throngs. Through whose rudeness and rashness only I doubt 
not, that a great number are cast away and destroyed (the more 
pity). For this cause and for the honour of Almighty God, and 
for the most bound service the which I owe unto your grace, 
most gracious and virtuous queen, I have judged my labour and 
pains in this behalf right well bestowed, requiring all other 
women of what estate soever they be, which shall by reading of 


the same find light and comfort, to yield and render thanks 
unto your most gracious highness, wishing greatly that it might 
please all honest and motherly midwives diligently to read and 
oversee the same, of the which although there he many which do 
know much more peradventure than is here expressed, yet am 
I sure in the reading of it their understanding shall be much 
cleared and have somewhat farther perseverance in the same. 
It is no small charge which they take upon them, for if when 
any strange or perilous case doth chance, the midwife be 
ignorant or to seek in such things which are to be had in remem- 
brance in that case, then is the party lost and utterly perished, 
for lack of due knowledge requisite to be had in the midwife. 
Wherefore I beseech Almighty God that this my simple 
industry and labour may be through your grace unto the utility, 
wealth, and profit of all English women, according to my utter 
and hearty desire and intent, to whom also I daily pray long 
to preserve and prosper your most gracious highness, both to 
the continual comfort and consolation of our most redoubted 
and without comparison most excellent Christian prince, and 
also the joy and gladness of his loving subjects. Amen." 

Of course, the Table of Contents of the 1540 or Jonas 
edition differs much from those of the Eaynalde editions of 1545, 
1552, 1560, etc. There is no reference in it to a Prologue, for 
no such thing exists in the 1540 issue, unless we regard the 
Eeligious Admonition and the Dedication as jointly constituting 
one. Then, we note the absence of the first thirteen chapters 
of the first Book of all the Eaynalde editions ; and the sixth 
chapter of the fourth Book of the Eaynalde editions, contain- 
ing the cosmetic suggestions or "bellifying receipts/' is not 
represented in the Table of Contents of the 1540 edition. 
Eoughly speaking, the Jonas or 1540 edition contains the second, 
third and fourth Books of the Eaynalde editions, plus the last 
chapter of the first Book and minus the last chapter of the fourth 
Book of these later editions. But T have already, in my former 


article, set forth in detail the differences between the Contents 
of the two issues (loc cit., p. 248). 

In the 1540 edition the preliminary matter closes with two 
interesting paragraphs dealing with weights and measures and 
with drugs and apothecaries ; they are peculiar to this edition. 
The former is introduced in these words : " For because that in 
this book many times be found certain measures and weights of 
physic, not known peradventure to all such as that chance to 
read it, therefore here briefly I have set them forth, showing 
the value and estimation of them so far as they shall be 
requisite to the better understanding of such things the which 
ye shall read in the same treatise." Then follows the table of 
the weights and measures, the pound being stated to contain 
5,762 grains. The second paragraph refers to the obtaining of 
the drugs named in the text of the book, and reads thus : " Ye 
shall also note here that many times ye shall happen upon 
strange names of such things the which are occupied about 
infirmities spoken of in this book, for the which theyr is no 
English but are used in their own proper names of Greek or 
Latin : and they are such for the most part which are to be had 
only at the apothecaries, being of them right well known ; 
wherefore when ye shall need any such thing if ye send the 
same names in your bill to the apothecaries they will soon 
speed your purpose: neither do this if ye may without the 
advice of some expert and learned physitian." 

I have now enumerated all the parts of the preliminary 
matter, both as found in the Eaynalde editions of the Byrth 
of Manhynde and in that first edition with which the name of 
Eichard Jonas is associated. I now pass to the Prologue, 
which is to English readers perhaps the most attractive part 
of the work. 


The Prologue. 

To the English obstetrician, as well as to the student of the 
manners and customs of the sixteenth century, the Prologue to 
the Women Readers will be by far the most interesting part of 
the book. It is not a translation of anything in Kosslin ; 1 it 
is not indeed a translation of anything at all. We may regard 
it as a piece of original writing fresh from the mind of 
Kaynalde, giving the history of the work and throwing an 
important sidelight upon the way in which obstetric matters 
were looked upon in England in the middle of the sixteenth 
century. There are, it is true, a few passages in it which are 
reminiscent of some parts of the Dedication to Queen Katherine 
in the 1540 edition ; but the greater part of it must be ascribed 
to Kaynalde. 

The intent of the author (" the entent of thauctour ") is to 
recite the sum and chief contents of the book, for it is " a great 
pricke or allurement, entising and meuinge a man, to reade any 
boke, when he is somwhat first admonyshed of the matters 
comprehended and contayned therein." Then, without giving 
any names, Kaynalde tells how the studious and diligent clerk 
[Jonas, to wit] made the English translation of the Latin work 
[by Kosslin] entitled Be Partu Hominis, and called it "the 
byrth of mankynde" ; it is now to be named "the womans 
boke." That translation is now to be corrected and augmented, 
revised "from top to to," as the writer quaintly says; and 
there are to be " set forth and evidently declared al the inward 
partes of women, and that not onely in wordes, but also in 
lyvely and expresse figures." Kaynalde beseeches the midwives 
who will read his book to pay special attention to these 
anatomical matters, for, he adds, " when a person is sycke or 
dyseased in any part, it is halfe a comfort, yea halfe his helth, 

1 There is a " Prologue "' in Rosslin's De Partu Hominis (edition of 
1538, Paris), but it has nothing in common with Raynalde's. 


to understand in what part the dysease is, and howe that parte 
lyeth in the bodye." 

The second part of his book ("the seconde booke") is to 
concern itself with labour, "with the byrth of mankind and 
al the daungers, perels, and other cases happenyng to the 
labourynge woman at that season." This portion of the work 
is to be illustrated with the Byrth Fygures and the picture of 
the Womans Stoole ; the first part had the anatomical figures 
from Vesalius to elucidate the text. 

The third book considers the choice of a wet nurse. " Item 
medicines encreasyng, deminishinge, attenuatyng, engrossinge, 
and amendynge the mylke in the nources brestes. Also 
remedies for manye and sundry diseases, which oft tymes 
chaunce unto infantes after theyr byrth." 

In the fourth book the author proposes to discuss the 
question of conception and the overcoming of sterility. " And 
farther in this last booke shall be uttered and set forth certayne 
embelleshinge receptes concerning onely honeste and helthsome 
decoration and clenlynes." The writer evidently feels that he 
is on dangerous ground, for he adds that he is to teach 
" nothinge in that place but that onely whiche may make to the 
honest, comely, and commendable conservinge and maintaininge 
of the inset and natural beautie in a woman, utterly abhorring 
and defying all farding, paynting, and counterfeit cast coulors, 
which of some dampnable and misproude people be dayly used, 
such as by all meanes possible, seke and search more the 
abhominable and divilish painting and garish setting forth of 
their mortal carcases (the better therby to commend it unto the 
eyes of foolish and fond men) than by honest, sober, debonayre 
and gentil maners, so to demene their life, that they may 
therby rather obtayne the loue, amitie, and hartie perpetual 
favour first of god, and then of al honest, discrete, and godly 
wise men." 

After giving this brief summary of the contents of the book, 


Kaynalde asks his women readers (" for whose sake and only 
respect it is set forth ") to give it their benevolent favour and 
good acceptation. He is quite sure, however, that to some the 
work will not be acceptable. Not even an invocation of the 
gods and goddesses (" great Apollo, wyttye Mercury, and sweet 
Suada ") will suffice to convince them who give so " precipitat 
and heady judgementes in all maner of matters," that the book 
is useful and good. Some will allege " that it is a shame, and 
other somme, that it is not meete ne fyttynge such matters to 
be entreated of so playnly in our mother and vulgare language, 
to the dyshonoure (as they say) of womanhed, and the derision 
of theyr wonte secretes, by the detection and disco verynge 
whereof, men it readynge or hearing, shalbe moved thereby 
the more to abhorre and loo the the company of women." But 
it is of no use to attempt to convince such people. Nothing 
is so good but it may be abused. Fire and water, meat and 
drink, the Bible, even the blessed Sacrament may be abused; 
but " to them that be good theimselfe, everye thinge turneth to 
good, whatever it be is to them a sufficient matter and occasion 
therein to seke the glory of God, and the onely profyte of 
their even Christen." " Wherefore," the writer concludes 
" consydering that there is nothinge in this world so necessary, 
ne so good, holye, or virtuous, but that it maye by wyckednesse 
be abused, it shalbe no great wonder though this lyttle booke 
also, made, written, and set foorth for a good purpose, yet by 
lyght and leude persons be used contrary to godlynesse, honesty, 
or thentent of the wryter thereof." 

The only possible dangers, so far as the writer can see, are 
that some of the medicines referred to may be employed for a 
criminal purpose ("some divelishe and lewde use"), and that 
the book falling into any " lyght marchauntes handes " may be 
used for the derision of women. That men by reading such a 
book should " conceave a certayne lothsomnes and abhorrynge 
towardes a woman," is answered by the fact that if this were 


so then " Physitians and chyrurgians wyves should greatly be 
abhorred and mysbeloved of theyr husbandes " ; and this is not 
so. "And I my self likewise, which wryteth thys booke, 
should mervaylouslye above many other abhorre or lothe 
women." Such " tender reasons " are petty and trifling ; " but 
to be short, there is no such thyng, neither any cause thereto 
why." In fact, it is rather to be expected that if, by any 
chance, a husband read the book, he may, if of a gentle and 
loving nature, do his wife good. 

Knowing as he does what the perils of childbirth are, the 
writer thought " it should be a verye charitable and laudable 
dede, and right thankefully to be accepted of al honourable 
and other honest matrones, yf by my paynes this lyttle treatyse 
were made to speake Englyshe, as it hath been longe syth 
taught to speake dutch, frenche, spanyshe, and dyvers other 
languages." The Byrth of Manhyde may, if properly read and 
consulted, supply the " roume and place of a good mydwife " ; 
as a matter of fact, the writer knows that it has been so used 
by " many honourable Ladies and other worshipf ull Gentle- 
women," and with much profit. But again it has to be 
confessed that there are some midwives who would have the 
book forbidden, "forsomuch as therein was descried and set 
foorth the secretes and privities of women, and that every boy 
and knave had of these bookes, reading them as openly as the 
tales of Eobin Hood, etc." "But here nowe let not the 
good midwives be offended with that, that is spoken of the 
badde. For verely there is no science, but that it hath his 
Apes, Owles, Bores, and Asses." The good midwives, however, 
were glad to get the book. " And thus I conclude and make 
an ende of this rude Prologue, requyryng the gentle readers 
thereof, that yf they shall fynde anything therein in terpre table 
to dyuers senses, to accepte onely that which may make to the 
best, accordynge to my meaning." 


The First Book. 

Like the Prologue, the First Book of the Byrth of Mankynde 
contains matter which is not to be found in Khodion's De Partu 
Hominis. Its contents are mainly anatomical descriptions. 
The writer is very sure of the " utilitie of the first boke " ; it is 
" as a key, openyng and clearyng the matters to be in treated of 
in the seconde." It deals with the "fourme, maner, and 
situacion of the inwarde partes of a woman/' with "the 
campe or fielde of mankynde to be engendred therein." 

An interesting paragraph deals with the relative importance 
of the sexes in the matter of procreation : " And although that 
man be as principall mouer and cause of the generation : yet 
(no displeasure to men) the woman doth conferre and con- 
tribute much more, what to the encreasement of the child in 
her womb, and what to the noryshment thereof after the 
byrth, then doth the man. And doubtlesse yf a man woulde 
demaunde to whom the chylde oweth most his generation, 
ye may worthily made aunswere that, to the mother : whether 
ye regarde the paynes in bearynge, other els the conferrence of 
most matter in begettyng." 

The organs are then described in detail. First, "the 
principal coates of the body " are referred to : they consist of 
the superficial skin or cuticula, of the "fleshye" skin or 
membrane carnosa, and of the third coat or adeps, which lies 
between the other two. "Immediately under the fleshye skin 
be conteyned the Muskles." Chapter III. of the First Book is 
specially concerned with the " Muskles," and particularly with 
those of the " bellye." These are the musculi obliqui descen- 
dentes or " the Byaswyse descendyng muskles " ; the musculi 
obliqui ascendentes or the " Byaswyse ascending muskles ; " the 
musculi recti or " the ryght muskles " ; and the musculi trans- 
versi or the " overthwart muskles." " All these f oure Muskles 


be to the entrayles and bowelles within the belly, as foure 
seuerall coates: by the vertue and helpe of whom, together 
with the ayde of the midwiffe, all expulsion both upward and 
downewarde in the guttes, in the stomacke, in the matrix of 
the woman in the tyme of labour, and also in the bladder in 
tyme of makyng of water, is wrought: and yet besides this 
utilitie, they clothe (as I have saide) defende, fortifie, and 
strength the inwardes of the belly." 

Chapter IV. of the First Book speaks of the " kell, called 
Peritoneum," a certain " thin rime " : it " yeldeth unto eche 
entrayle a coate and webbe of the cloth of his owne body : by 
the whiche his livery, they be the more arctly and straightly 
affixed or fastened unto hymselfe." Chapter V. gives the 
declaration of the names and nature of the Matrix. "The 
Matrix, the Mother, and the wombe, do signifie but one thing, 
that is to saye : The place wherein the seede of man is con- 
ceaved, fetified, conserved, nourished, and augmented, unto the 
tyme of deliuerance, in Latin named Uterus and Matrix." 
From the description which follows, it is evident that the 
writer intends by "Cervix Uteri" the vulva and vagina. 
Chapter VI. deals with " the wombe and his partes." " Nowe 
ye shall understande, that the founde or bottome of the 
matrix is not perfectly round bowlwyse, but rather lyke the 
forme of a mans heart, as it is paynted, sauinge that the 
particion or clifte in the matrix betwene both corners, the 
ryght and the lefte, is not so profoundlye dented inwardes as 
the clyfte in the hearte." From this description it would 
almost appear as if the uterus of one of the Mammalia were 
intended, or if the writer had come across a case of minor 
malformation of the organ (uterus septus) in the human 
subject. He is quite sure, however, that there is only one 
" holonesse " in the womb ; he does not believe in the seven 
"selles" said to be therein. "In tymes passed, dy verse 
Clarkes haue written, and many other haue beleued, that 


there shoulde bee seuen selles, or seuen distinct places in the 
Matrix, in thre of the whiche, on the ryght syde shoulde onely 
men chyldren be conceyued, and in the other three on the lefte 
syde women chyldren, and yf it chaunced that the seede were 
conceaued in the seuenth sel, whiche was the myddelmoste, 
then that shoulde become a monster, halfe a man, and halfe a 
woman. The whiche all is but lyse, dreames, and fonde 
fantasyes : for the womans Matrix, as I haue saide, is euen as 
a stronge bladder, hauinge in it but one uniuersall holones, 
and the chylde when it lyeth in it, lyeth euer on the one syde 
more then on the other, the head beynge towardes one of the 
corners or angles, and not upryghte towarde the myddle 

Chapter VI. (VII. correctly) speaks of the " Mother port." 
This is the Cervix as we nowadays call it. " It is of the forme 
of a haukes bell, or other lyttle mores belles" (i.e., morris 
bells). At certain times, "the Matrix beynge apte and 
dysposed thereto, and other conditions requisite, thys wombe 
porte do naturally open it selfe, attractinge, drawing and 
suckinge into the wombe the sede by a vehement and naturall 
desyre." During pregnancy it remains closed, "untyll the 
tyme of delyueraunce, at what tyme agayne it delate th and 
openeth it self, in such amplytude and largenesse, that it is 
wonderfull to speake of." 

Chapter VIII. contains a description of the vessels of seede, 
called the woman's stones, i.e., the ovaries as we now know 
them, "wherin is engendred the seede and sparme that 
commeth from the woman, not so strong, ferme, and myghtie 
in operation as the seede of man, but rather weake, fluy, colde, 
and moyste, and of no great firmitie." But, the writer tells 
his readers, the woman's seed is just as proper for its purpose 
as the man's. "These stones be nothynge so bygge as the 
stones of man, but lesse, natter, much fashyoned after the 
shape of a great and brode almonde." 


Chapter IX. has to do with the " sede bringers," not, let it 
be borne in mind, the Fallopian tubes, but the " two vaynes 
and twoo artyres which come to these two stones." Here we 
find a description of the blood-vessels of the pelvis along with 
the views then held as to the origin of what was called the 
" woman's seed," which are set forth at length in Chapter X. 
These views have now only an historical interest, for the 
physiological knowledge on which they rested has long since 
been replaced by more correct information. To the curious, 
however, the description given of the four "mines" shops or 
workhouses existing in the body cannot but be attractive. 
" Of this sort of mines, there be foure principall in the bod ye 
of man. The first is the mine of bloud, which is the lyuer, in 
whom the iuyce of meate, before of colour whyte, is transmuted 
into red, made apt and fitte to nourishe all partes of the body, 
attract and drawen out of the stomacke and guttes, thorow 
verye small and infinite lyttle vaynes into the lyuer. The 
seconde mine is the heart, which of the bloud attracte and 
drawen from the great maister vaine, proceading out of the 
foresayde lyuer, into his parlers, doth engendre vehement and 
liuely spirite, conmixed with depured and greatly elaborated 
bloud, within the selles of the heart, from thence sent forth 
throw the artires, into all partes of the bodye, being in colour 
yealowyshe, thinne, and hoote bloud. The thyrde mine is the 
brayne, of whom all the sinewes take thyr originall. In whom 
the wyttye spirite, the spirites of mouyng, and the spirites of 
al sensibilitie be engendred, and thorow the sinewes sent to all 
partes of the bodye. For all suche partes as moue and feele, 
haue that by reason of sinewes derived unto those places from 
the head. The fourth mine is the stones, in whom by commix- 
tion of al the other thre foresaid metalles of the body, that 
is to say, vayne bloud, arteriall bloud, and liuely spirites 
engendred in the head, is engendred and produced sede, whioh 
bestowed in his due place becommeth like in perfection to the 


creature from whence it came ; that is to say of mankynde, 
man." The writer then goes on to explain how " the seede is 
receaued into the stones/' how the colour of the seed is trans- 
muted, and how the seed in woman is not so firm as in 
man, etc. 

Chapter XL tells how the seed (of the woman) is sent from 
the stones to the angles or corners of the Matrix by means of 
a " wormye bodye," evidently the Fallopian tube. The seed in 
woman is supposed to be for the purpose of moistening the 
genital passage as " with a dewe." The writer then proceeds 
to moralize on what he terms the " prickes of nature." " For 
yf that the God of nature had not instincted, and insette in 
the body of man and woman, such a vehement and ardent 
appetite and luste, the one lawfully to company with the 
other: neither man ne woman woulde neuer haue ben so 
attentyfe to the workes of generation and encreasement of 
posteritie, to the utter decaye in shorte tyme of all mankynde. 
For ye shal heare some women in tyme of theyr trauayle, 
meued through great payne and intollerable anguyshe, forswere 
and vowe them selfe, neuer to companye with a man agayne ; 
yet after that the panges be passed, within short whyle, for 
entyre loue to theyr husbandes, and singular naturall delyte 
betwene man and woman, they forget both the sorow passed 
and that that is to come. Suche be the privie works of God, 
and suche be the prickes of nature, which neuer createth no 
special pleasure unaccompanyed with some sorow: neither is 
there for the most part any sorow, but that it hath annexed 
some ioy or comforte, lesse or more, to alleuiate and lyghten 
the burthen and weyght of displeasure." 

Chapter XII. deals with the bladder in women, with stone 
(" but women be not so prone ne apt to engender the stone in 
the bladder as men be "), and with the reason why the urine 
when it has reached the bladder does not revert again. 

Chapter XIII. is a very interesting one, for in it are con- 


sidered not only the " vaynes which resort to the Matrix/' but 

also " the termes and theyr course with the causes thereof." 

" Nowe to come to the declaration of the nature of termes, ye 

shal understand that thei be called in Latine Menstrua, for 

because that ons in a moneth they happen alwayes to woman- 

kynd, after XIII. or XV. yeares of age passed (beynge in theyr 

perfect health) : In Englyshe they bee named Termes, because 

they retourne eftsoones at certayne seasons, tymes and termes." 

Having described, as best he knew, how the blood was poured 

into the Matrix, the writer goes on to tell the cause of the 

terms, that they are really intended to serve as nourishment 

for the foetus ("feature"); for "prudent Lady nature" has 

wisely so provided ; " yea, although the woman do neuer 

conceaue .... yet is there no faute in nature, who hath 

prepared place, and foode to be at al tymes in readynes." It 

is noted, also, that women that have no terms cannot bear 

children ; that the terms do not follow the waxing and waning 

of the moon exactly ; and that the duration of the flow varies 

in different women. 

In Chapter XIV. are considered at some length the three 
cauls or wrappers "wherein the infant is lapped" in the 
uterus. The innermost caul is named the Amnios, " in Latine 
Agnina, for cause it is as dilicate as lambes bee." " The 
mydwifes commonly call it the coyfe or byggyn of the chylde, 
and some call it chyldes shert, the which also many times 
proceadeth alone with the chylde, eyther uppon the chyldes 
head, or one of the armes or legges. And then the women 
reserve it as a thynge that shoulde betoken some grat lucke to 
the chylde in tyme to come." "The seconde wrapper or 
caule in Greek is called Allantoides, in Latine Farciminosa, in 
Englyshe these two termes do signifie haggiswyse for because 
that it is fashioned much after the shape of the outwarde 
skynne or bagge of an haggisse puddinge." This second caul of 
Eaynalde is our modern chorion apparently, while the third 


which he names Chorion or Secundina (or hoop caul) would 
seem to correspond to the placenta; but the description is 
vague and shows no evidence of close observation of nature. 
The description of the vessels of the umbilical cord is more 
exact. " Thorow these Ar tires, liuely spirite and freshe ayre 
is deriued out of the mother into the chylde, wherwith the 
naturall heate of the chylde is viuified and refreshed. And 
these two Artires with the foresayde nauyll Vayne, when the 
childe is borne, begin to wyther and drye, euery day more and 
more, and become much like a harpstryng, without any holow- 
nesse or cauitie." The urachus ("another vessell") is also 
described, and it is said that by it the urine passes from the 
bladder to the space between the first and second caul without 
the child's body. The placenta (" chorion ") is compared to the 
spleen or melt " in a man or beast " ; " so that to be short, 
Chorion is the immediat receptacle and receauer of al the 
vaynes and artires, to be deduced from the Matrix to the 
chylde, and the chylde recaueth onely at his hand the two 
Vaines and Artires, whiche by the way as they passe and perse 
thorow the other two caules, towardes the chyldes Nauyll, they 
sende into eche of the caules innumerable small eye vaynes 
and artires, whereby the caules be sustayned and encreased 

The terms, when there is a foetus in the uterus to be 
nourished, are no longer superfluous but are used in supplying 
nourishment to the infant in utero, and that part which is not 
needed goes to the breasts to become milk. It is not right to 
regard the terms as a purgation, for the blood of which they 
are composed is as pure and wholesome " as all the reste of the 
bloud in an ye part of the body els." " Yet much more are to 
be detested and abhorred, the shameful lyes and slaunder that 
Plinie, Albertus magnus de secretes Mulierum, and diuers other 
mo haue written, of the venimous and daungerous infective 
nature of the womans Flowres or Termes : the which all be 


but dreames and playne dotage. To rehearse theyr fond wordes 
here, were but losse of inke and paper, wherfore let them passe 
with theyr auctours." It is not a little amusing to read such 
denunciations of Pliny and Albertus Magnus following so 
closely after some of the anatomical descriptions that have 
gone before; but in his views upon the functions of the 
placenta as set forth in the following paragraph the writer 
is far in advance of his time. " Forbecause that she (Nature) 
woulde that the pure bloud commyng from the Matrix vaynes, 
should be made yet purer, she suffereth not the same to entre 
immediately into the infante, but first useth another meane, 
and sendeth it into Chorion or the hoope call (as I haue sayd 
before), where truely it hath a certayne circulation, and another 
digestion, wherby it is desecate, and clensed very exquisitly, 
by the diligentis of nature attenuated and fined, and so at the 
laste sent foorth into the infant, leauyng all the grosser part 
in the spungye bodye of the hoope caule." (It is to be re- 
membered that the hoop-caul is the placenta.) 

The Fifteenth Chapter is concerned with some curious 
considerations regarding which of the three Matrix veins 
contain the Terms and how the milk comes to the woman's 
breasts. The importance of knowing which of the veins 
contain the menses is, the writer thinks, at once evident when 
we have to deal with too much or too little monthly flow ; to 
put these anomalies right we have to apply medicines, and if 
the menses come only from the veins of the neck of the womb 
there will be no use in applying medicines to those of the 
fundus. The writer is of opinion (for reasons which it is 
unnecessary to discuss now) that the terms come from the 
veins at the fundus only. It is in this connection that the 
writer relates the history of two cases in his practice, the one 
in London and the other in Paris, to which reference has 
already been made {Edin. Obstet. Trans., vol. xxxi., p. 243, 

Fig. 1. 

Illustration taken from Vesalius's De Hurnani Corporis Fabrica 
(Edition of 1543), where it is the Twenty-fifth Figure of the 
Fifth Book ; it appears as the Second Figure in the Byrth 
of Mankynde. 

[Between pages 256 and 257. 

Fig. 2. 

Illustration taken from Vesalius's De Hwmani Corporis Fabrica (Edition of 1642), showing 
the Nine Figures which were used by Raynalde to illustrate the Anatomical Part of 
the Byrth of Mankynde. 




Fig. 3. 

Figure from Vesalius's De Humani Corporis Fabrica (Edition of 1543), representing the 
Dissection of a Man's Body. It appears as Fig. 1 of the Anatomical Figures of the 
1545 and 1552 Editions of Raynalde's Byrlh of Mankynde, but is omitted from that 
of 1560 and from all subsequent ones. 

Fig. 4. 

Figure from Vesalius's De Humani Corporis Fabrica (Edition of 1543), 
representing the Dissection of a Man's Body. It appears as 
Fig. 2 of the Anatomical Figures of the 1545 and 1552 Editions 
of Raynalde's Byrth of Mankynde, but is omitted from all the 
subsequent ones. 

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Fig. 9. 

Figure of Twins in Utero, from Rhodion's Be 
Partu Hominis (Edition of 1538), where it 
appears on folio 29. 

Fig. 10. 

Figure of Double Monster in Utero, from Rhodion's 
Be Parlu Jlominis (Edition of 1538), where it 
appears on folio 11. 


There is much else in this chapter about clots in the terms, 
about the " white flowers," about retention of the terms, and 
about the manner in which " the mylke which commeth to the 
brestes is engendred of the Termes (accordyng to moste mens 
opinions)." There is not wanting evidence, it is pointed out, 
of the "great familiaritie betwene the Matrix and the brestes, 
for so much as the ebbyng of the one is the flowinge of the 

Such are the matters dealt with in the First Book of the 
Byrth of ManJcynde in the 1560 edition; it remains for me now 
to examine the differences which exist between this and other 
editions. The 1545 and 1552 editions call for no special 
comment, and those that were published later than 1560 also 
show none other than trifling alterations; but the Jonas or 
1540 edition differs widely from the rest. 

The First Book of the 1540 edition is really the Second 
Book of the Kaynalde editions (with some exceptions to which 
reference will be made), and the First Book of the Eaynalde 
editions finds no counterpart, or almost none, in the 1540 
edition. Almost none, for the First Chapter of the latter 
contains an account of "how many caules the birth is 
compacted and wrapped in," and the fourteenth chapter of the 
Eaynalde editions deals with "the three caules or wrappers 
wherein the infant is lapped." Chapters I. to XIII, Chapter 
XV., and part of Chapter XIV. of all the Eaynalde editions 
find no counterpart in the 1540 edition of Jonas; practically 
the whole of the First Book of the Eaynalde editions, therefore, 
is new material added to what was in the 1540 edition. To 
trace the source or sources of the new material found in all the 
Eaynalde editions would be an interesting literary investigation, 
but it is one which I am not now in a position to make. I 
may, however, state that no part of the added chapters is in 
the two editions of Eosslin's De Partu Hominis which I have 
been able to examine (those of 1538 and 1556); and in the 



meantime it is only reasonable to ascribe it to Raynalde, and 
to regard it as part of the " augmentation " mentioned on the 
title page of the 1545 and subsequent issues of the Byrth of 

The Anatomical Figures. 

At the end of the First Book is " The declaration by letters 
of the fygures folowing, wherein be set forth to the eye euery 
parte in woman mentioned in thys boke before: Which in 
the former Printinges hath ben corrupted, but nowe truely set 
forth." These figures are nine in number, and they have all 
been reproduced in Plates IV., V., VI., and VII. of my former 

No indication is given in the letterpress as to the source of 
the illustrations ; indeed from the reading of the accompanying 
descriptions it would seem that they were original, and that 
the objects depicted in them had been seen by the writer. A 
little investigation, however, soon shows that this was not the 
case. None of them is to be found in the 1538 edition of 
Rosslin's De Partu Hominis, although four of them make their 
appearance in the 1556 edition ; but, then, as we shall see, they 
had already appeared in the 1545 edition of the Byrth of 
Manhynde and had been repeated in the 1552 edition. Evidently, 
therefore, their original source is not Rosslin's work. As a 
matter of fact, they have been taken, description and all, 
from Vesalius's book De Humani Corporis Fabrica, in the 
"first" or 1543 edition of which they are all to be 

I have carefully compared the plates in the 1560 edition of 
Raynalde's Byrth of Manhynde with those in the 1543 edition 
of Vesalius's work, with the following results : — The first figure 
in Raynalde is the twenty-fourth of the Fifth Book of Vesalius, 
and is found on p. 377 of that work, with the descriptive letter- 


press on pp. 376, 377, and 378 ; the second figure is the twenty- 
fifth of Vesalius, and is found on p. 378, with its description on 
pp. 379 and 380 ; the third figure is the twenty-sixth of Vesalius 
on p. 380; the fourth figure (IIII.) is also to be found in 
Vesalius's work at the end of his Third Book, on p. 313, 
with its description; Figures V., VI., VII., and VIII. of 
Eaynalde's work are the first, second, third, and fourth 
separate figures in the thirtieth plate of Vesalius's Fifth Book, 
and are to be seen on p. 382, with descriptive notes on p. 
383; and the ninth figure of Eaynalde's Byrth is the 
twenty-seventh of the Fifth Book of Vesalius's Be Humani 
Corporis Fabrica, where it is to be found with its description 
on p. 381. 

All these figures, as they appear in the 1560 edition of 
Eaynalde have been reproduced in my former article, where they 
are numbered Figs. IV., V., VI., and VII., but, in order to pre- 
vent confusion, their proper numbers (I., II., III., IIII., V., VI., 
VII., VIII., and IX.) are also attached to them (although some 
of them were reversed in the original printing, e.g., IV., VII., 
and IIIV. for VI., VII., and VIII.). In order that the reader 
may compare the plates as they appeared in Vesalius's work 
with their reproductions in Eaynalde's 1560 edition of the 
Byrth, I give here Vesalius's twenty-fifth figure corresponding 
to Eaynalde s Fig. II. (Fig I.) : it can be studied alongside of 
the Eaynalde reproduction (Fig. V. of my former article). 
Further, in a later edition of Vesalius's work (that of 1642) 
all the nine figures used by Eaynalde were grouped 
together in one plate (on p. 96), and I have thought it 
worth while to reproduce this also (Fig. II.). It represents 
in graphic form Eaynalde's unacknowledged indebtedness to 

The descriptions of the figures are literal translations of the 
Latin text which accompanied the illustrations in Vesalius's Be 
Humani Corporis Fabrica. I give here in parallel columns 



the Latin description of Figure II. and the English translation 
of it:— 

A praesentis figurae dextra 
mamilla cutem abstulimus, ut 
quam fieri posset proxime mamil- 
larum natura hie oculis subji- 
ceretur. Deinde ventriculum, et 
cum intestinis mesenteriuin et 
lienum resecuimus, recto interim 
intestino non secus quam in mox 
praecedente figura relicto. Ad 
haec, uterum suo extimo quod 
peritoneum ipse porrigit involucro 
quodammodo spoliavimus, omnes 
membranas quam licuit accura- 
tissime passim, ideo amputantes, 
ut seminis materiam testibus 
def erentia et rursus semen ab his 
utero deducentia vasa in con- 
spectum venirent. Vesicam vero 
deorsum in sinistrum latus reflexi- 
mus, una meatum a dextro rene 
ipsi urinam deferentem abrum- 
pentes, ut urinam vesicae depren 
tium meatuum insertio appareret, 
ipsaque vesica uteri inspectionem 
non occuparet. Postremo pubis 
ossium portionem ab hac figura 
exsecuimus, quo uteri cervix ac 
vesicae etiam collum apposite 

We have here taken away the 
skyn from the ryght teate of this 
present figure, that the nature of 
the teates mighte as nygh as may 
be, be set before the eyes, and 
afterwards we have cut awaye 
the ventricle with the bowels, and 
also Mesenterium and the splene, 
leaving the strayte entrayle in 
thys place unmedled with, as well 
as we dyd in the fygure before. 
And moreover, we have as it were 
taken awaye from the uttermooste 
cote which Peritonium gave unto 
it, cutting away also al the pan- 
nicies, that the vessels caryinge 
forth the substaunce and matter of 
sede to the stones, and also the 
vessels carying away the sede 
from thence to the Matrix shoulde 
appeare-and bee seene. Also we 
have tourned over the bladder 
downewarde on the lefte syde, 
lykewyse breaking the way or 
conduite which beareth foorth 
the urine to it from the ryght 
kydneye, that the insertion of the 
wayes of bearyng forth the urine 
to the bladder myght appeare, and 
that the bladder shuld not let the 
inspection or sight of the Matrix 
or Wombe. Last of all we have 
cutte away from this fygure a 
portion of the bones above the 
privie membres, thot the neckes of 
the matrix and of the bladder might 
the more commodiously be sene. 


The comparison of the Latin description with the English 
translation leaves no donbt that Raynalde boldly appropriated 
both the plates and their accompanying text from the work of 
Vesalius ; he was not even at the trouble of altering personal 
details which referred to Vesalius, such as the allusion to his 
work at the University of Padua which occurs in the explana- 
tion of the ninth figure. In this respect, however, he did not 
differ from the editor of some of the later editions of Rhodion's 
Be Partu Hominis {e.g., that of 1556), who also borrowed some 
of Vesalius's plates without acknowledgment. 

What has been said above refers to the 1560 edition of 
Raynalde's Byrth of Mankynde. When we turn now to the 
1545 and 1552 editions we find two other anatomical figures 
(making eleven in all), named the fyrst and second fygures, 
along with several differences in the accompanying descriptive 
letterpress. The wording of the Declaration differs slightly, 
the reference to corruptions in the printing not appearing. It 
reads: "The declaration by letters of the fygures folowyng, 
wherein be set forth to the eye every part in woman mencioned 
in thys Boke before." The first and second figures, however, 
represent dissections of a man's body, and at the end of the 
descriptive letterpress the editor somewhat ingenuously says : 
" Here ye shal be advertysed that although these ii fyrst fygures 
be made principally for ye man, yet may they serve as wel 
to expresse the woman : for the man and woman differ in 
nothyng but in the pryvie partes." These two illustrations also 
are borrowed from Vesalius's Be Humani Corporis Fabrica, 
where they appear on pp. 355 and 356 of the 1543 edition, and 
are named the first and second figures of the Fifth Book. They 
are reproduced here as Plates III. and IV. I place, again in 
parallel columns, the Latin and the English, and it will be noted 
that the latter is not so strictly a translation of the former as 
in the descriptions of the 1560 edition : — 

Praesenti figura tanta humani In the fyrst fygure is set forth 



corporis portio delineatur, quanta 
ad peritonaei sedes ostendendas 
sufficit : exprimitur itaque hac 
figura anterior peritonaei sedes, 
sectionis serie ab octo abdominis 
musculis libera, nullaque ex parte 

A,A,B,C,D. His characteribus 
peritonaeum insignitur, quodamo- 
doque hac figura terminatur. 

E,E. Linea a mucronata pecto- 
ris ossis cartilagine ad pubis usque 
ossium commissuram procedens, 
cui oblique descendentium et as- 
cendentium, et transversim pro- 
cedentium abdominis musculorum 
nervosae tenuitates pertinacissime 

F. Umbilicus, quern inter dis- 
secandum etiam adeptis abdominis 
musculis, gratia opportunae um- 
bilici vasorum demonstrationis, 
reservare solemus. 

G. Seminaria sinistri later is 
vasa suis membranis, quas a peri- 
tonaeo mutuantur, adhuc obvoluta. 

H. Seminaria dextri lateris 

I. Vena ac arteria quae potis- 
simum inferiori sedi rectorum 
abdominis musculorum exporri- 
guntur, quorum et hie quoque 
l>ropendet portio. 

K. Vena et arteria, quae sub 
osse pectoris exporrectae, in an- 
teriorem abdominis sedem prola- 
buntur, praecipue rectis abdominis 
oblatae musculis, ac superiore ab- 
dominis sedem universam quoque 
implicates : quemadmodum illae 

so moch of a man's body as may 
be sufficient to show the forme 
of thee kell called Peritoneum : 
spoken of in the iiii Chapter, 
Whose compasse is here noted 
wyth A,B,C,D. 

A,A. Noteth the grystell, nether 
ende or poynt of the brest plate, 
in the pyt or pitch of the brest 
agaynst the stomacke. 

E,E. is a lyne descendyng upon 
Peritoneum from the sayde grystle, 
downe to the myddle joynt of the 
share bone. 

F. is the navell. 

G. sygnifieth the sede vessels of 
the lefte syde in men descendynge 
out of the amplytude of the 

H. is the ryght seede vessell : 
but thys G. and H. hath no place 
in the women. 

I. sygnyfieth the ascendinge 
vayne and arty re mencyoned in the 
last chap. 

K. the descending brest vaynes 
and artyres spoken of in the same 
Chapt. as for other letters that be 
in this figure I wyl make no 
further declaration of them, for 
because they serve nothing to this 
present purpose. 


quas insignivimus, humiliore et 
pubis ossibus viciniore implicat. 

L. Venarum soboles in peri- 
tonaei latera excurrentium, ac ab 
illis venis deductarum, quae aut a 
conjuge carente vena, aut geni- 
culatim a cava pronascuntur, qua 
ipsius caudex lumborum vertebris 
colugatur, etc. 

Other differences between the edition of 1560 and those of 
1545 and 1552 remain to be noted. These consist chiefly of 
verbal differences in the descriptions of the figures. Figures 3, 
4, 5, 6, 7, S, 9, 10, and 11 of the earlier editions correspond to 
Figures 1, 2, 9, 3, 4, 5, 6, 7, and 8 of the 1560 edition. To 
show the extent of the verbal changes I place here in parallel 
columns the description of the fifth figure of the 1552 edition 
and the ninth figure of the 1560 edition; they represent the 
same specimen, but, as will be seen, differ considerably : — 

1552 Edition. 1560 Edition. 

This 5 fygure is pourtrayed after And the nynth figure sheweth 

ye quycke, bothe in length and the Matrix cut forth of the body, 

bredtli, according to the length being of that bygnesse as it was 

and bredth of the matrix of a sene taken foorth of a woman at 

woman which was cut open for the the laste Anothomye, which I dyd 

same purpose by phisitions. But se at the universitie of Padua in 

ye must understand that here ye Italy. And moreover we haue so 

founde or body of ye wombe or devyded and cutte a sunder the 

matrix is devyded in ye myddes : bottome of the Matrix by the 

the forepart of the which, is turned myddle, that the concavitie and 

up, for because that ye maye the hollowe bought within the same 

better perceave ye cavite of the myght be perceaved, and the thicke 

matrix signed, the uppermost with substaunce also of both the coates 

A.A.C. The nethermoste halfe of the Matrix in women, when 

wyth B.B.D. Item. C. in the they be not with chylde. 

uppermost halfe and D. in the A.A.B.B. The concavitie and 

nethermost halfe show the seame holowe bought of the bottome of 

or lyne spoken of cap. vi. E.E. the Matrix. 



both in the upper and also in the 
nether betoken ye crassenes or 
thickenesse of ye inner coate, wall 
or skyn of the matrix in wemen 
not beinge with chyld, through 
the contraction thereof as ye shall 
farther rede in the sayd. vi chapt. 
F.F. the propendynge or heldynge 
parte of the seme in the matrix 
spoken of. cha. vi. G.G. is the 
porte, oryfyce, or gate of the 
wombe. H.H. is the second and 
utter coate of the matrix geven to 
it from Peritoneum. I.I. on both 
sydes of the necke of the matrix, 
do sygnifie, part of the kel called 
Peritoneum, sticking yet to the 
sydes of the Matrix and the 
necke thereof. K.K. is the place 
where the matrix is fastened to 
the upper part of the privy 
passage, ca. vii. L. signifieth 
the stub of ye bladders necke, 
wher it entreth into ye forepart of 
ye privy passage. 

CD. A line somewhat after 
the maner of a seame called in 
Latin Scortum, which doeth be- 
longe to the place wherein the 
testycle doo lye, whiche swelleth 
somewhat foorth into the bought 
of the bottome of the Matrix. 

E.E. The thickness of the inner 
and proper coate of the bottome 
of the matrix. 

F.F. A portion of the inner- 
more bottome of the Matrix, swell- 
yng foorth downeward from the 
hygher seate of the Matrix, into 
the holownes and bought of the 

G.G. The beginning of the 
necke or the opening place of the 
bottome of the Matrix. 

H.H. The seconde or uttermore 
infolder of the bottome of the 
Matrix, descended from Peri- 

I.I. Here we have reserved a 
portion on bothe the sydes of the 
thinne coverynges, descended from 
Peritonium, and conteynyng the 

K. Here is also sene the sub- 
staunce of the necke of the Matrix, 
because the cuttyng wherewith we 
devyded the bottome of the Matrix, 
was begunne at this place. 

L. A part of the necke of the 
bladder, implanted into the necke 
of the Matrix, castynge foorth into 
it the urine. The swellyng partes 
of Abdomen and whatsoever is els 
to be considered thereof, they may 
be sufficiently knowen without 
derection of Karacters. 


On comparing these two descriptions with the original 
Latin inscription found in Vesalius's work, I find that the first 
is a free and the second a literal translation thereof. In the 
first (that of 1552) all mention of Padua is omitted, while in 
the second (that of 1560) it is referred to, with the addition of 
the words "University of" and "in Italy," which are not in 
Yesalius's text. On the whole, we must accept as substantially 
correct the statement made in the 1560 edition, that "the 
declaration of the fygures ... in the former Printinges hath 
ben corrupted, but is nowe truely set forth," if by that is 
meant a closer adherence to the text of Yesalius's work. 

The Jonas edition of 1540 is supplied with no anatomical 

The Second Book. 

The contents of the Second Book (of all editions subsequent 
to that of 1540) are of less interest to English obstetricians, for 
they are simply a translation, rather free perhaps, of Ehodion's 
book Be Partu Hominis. I shall first enumerate the subjects 
dealt with in this Book, taking again the edition of 1560 as the 
standard Eaynalde one, and I shall then compare the matter as it 
appears in the various editions, and consider the character of the 
translations with which Jonas and Eaynalde have furnished us. 

The first chapter of the Second Book of the 1560 edition 
(and of all the others, except that of 1540) corresponds to the 
second chapter of the work of Ehodion (which is not divided 
into " Books," but simply into twelve chapters). 

Chapter I. begins with a short paragraph summarizing the 
contents of the First Book, and then proceeds to deal with " the 
tyme of byrth, and which is called naturall or unnaturall." The 
premonitory signs of labour are named : " first certaine dolours 
and paines begin to growe about the guttes, the Navyll, and in 
the raynes of the backe, and lykewyse about the thyghes, and 
the other places beynge neare to the privie partes, which lyko- 



wise then beginneth to swell and to burne, and to expell 
humours, so that it geveth a plaine and evident token that the 
labour is nere." Then comes a definition, which at least does 
not err by entering too much into detail : " Naturall byrth is 
when thy chylde is borne both in due season and also in due 
fashion." The due season is " most commonly after the ninth 
moneth, or about fortie wekes after the conception " ; and then 
follows that oft-repeated and widely-believed statement about 
the poor chances of survival which an eighth month child has 
as compared with one born at the seventh month (when " the 
chylde proveth very well "). The writer is somewhat in error 
when he describes the " due fashion " : " first the heade 
commeth forwarde, then foloweth the necke and shoulders, the 
armes with the handes lying close to the body towardes the 
face and forepart of the chylde, beyng towardes the face and 
forepart of the mother, as it appeareth in the first of the byrth 
figures." This definition makes, therefore, a face to pubes case 
the natural one, which is, of course, an error. The author 
(Rhodion) is on safer ground when he states that " yf the byrth 
be naturall, the dely veraunce is easy without longe tarying or 
lokynge for it." The " byrth not natural is, when the mother is 
delyvered before her tyme, or out of due season, or after anye 
other fashion then is here spoken of before : As when both the 
legges proceade fyrst, or one alone, with both the handes up, or 
both down, other els the one up and the other downe, and 
dyvers otherwyse, as shalbe hereafter more clerely declared." 
The "other els" as stated in the next chapter is " sidelonge 
(the which is most perellous) or arselonge, or backlonge, other 
elles (havinge two at a byrth) both proceade with their feet 
fyrste," etc. 

Chapter II. deals with "easy and uneasy, difficult, or 
dolourous deliveraunce, and the causes of it : with the signes 
howe to knowe and foresee the same." " Verye manye," says 
the writer, "bee the perylles, daungers and thronges, which 


chaunce to women in theyr labour, which also ensue and come 
in dyvers waves, and for dyvers causes, such as I shall here 
declare." Among the causes of delay in labour several are 
enumerated which are nowadays little accounted of or not 
considered at all, while others are omitted which are of 
importance. Few, for instance, will agree with the statement 
that the " byrth of the man is generally easier then the byrth 
of the female." Some of the causes are curiously set forth, 
such as, if the mother be " too spare or leane, or that she never 
had chylde before, or that she be over timorious and fearefull, 
dyvers, waywarde, or such one that wyll not be ruled, removy- 
ing her selfe from one place to another." The old belief in 
the birth of the child by its own efforts appears in such 
statements as : " yf the childe be so faynt, weake and tender, 
that it cannot tourne it selfe or doth it very slowly ; " " also if 
the childe be dead in the mothers belly, it is a very perellous 
thing, for so much as it cannot be easely turned, neither can it 
welde or helpe it self to come forth, or if the chyld be sicke or 
weakned so that it cannot for feblenes helpe it self." Then, 
various signs are enumerated to help the midwife to tell in 
what cases the unborn infant is weak or sick, such as if the 
pregnant woman has been " sore lasked," * if she have had 
" dayly and unwontly her flowres," if " strayght after one moneth 
upon the conceptyon her brestes yelde any milke." Causes of 
delay due to teratological states were not unknown to the writer, 
for he says that there will be difficulty if that with which the 
woman laboureth " be a monster, as for example, yf it hath but 
one bodye and two heades, as appereth in the XVII. of 
the birth figures such as of late was sene in the dominion of 
Werdenbergh." 2 Faults in the "secondine or latter birth" 

1 Lasked, purged. 

2 Werdenbergh, a town in Switzerland on the Rhine, in the Canton 
of St Gall. The monstrosity referred to appears as fig. x., near the end 
of this article. 


(membranes), such as firmness or slenderness are also named, 
and the delay due to loss of humidities from early rupture is 
referred to. "And farther if the woman have used to eate 
commonly suche meate or fruytes, which do exiccate or drye, 
and constrayne or bynde, as Medlars, Chestenuts, and al sowre 
fruites, as Crabbes, Chokeperes, 1 Quinces and suche other, with 
over muche use of Vergeus, 2 and such lyke sowre sauces, with 
Eise, Mill, 3 and many other thynges, all thys shall greatly hynder 
the byrth." " Also," the writer continues, " the use of colde 
bathes after the fyrst moneth folowing the conception, or to 
bathe in such water where Alome is, Iron, or Salt, or anye 
suche thynges whiche do coarcte and constrayne, or yf she have 
bene often tymes heavye and mourninge, or ill at ease, or yf she 
have bene kepte over hungry and thursty, or have used over 
much watche and walkinge, eyther yf she used a lyttle before 
her labour things of great odour, smel, or savour, for suche 
thynges (in manye mens opinions) attract and drawe upward 
the Mother or Matrix ; the which is great hinderaunce to the 

The chapter closes with an enumeration of the tokens of an 
easy labour. "Nowe sygnes and tokens of an expedite and 
easie delyveraunce, be suche as be contrarye to all those that 
have ben rehearsed before. As for example, when the woman 
hath bene wonte in tymes passed, easely to be delyvered, and 
that in her labour she feele but little thronge or dolour, or 
though she have great paynes, yet they remayne not still in the 
upper partes, but descend alwaies downewardes to the nether 
partes or bottome of the belly. And to be short, in all payne- 
full and troublesome labours these signes betoken and signifie 
good spede and lucke in the labour : unquietnes, much styringe 

1 Choke-pear, any "rough, harsh, and unpalatable variety of the 
pear, used for perry," a sort of crab-pear. 

2 Vergeus, or verjuice, a liquor expressed from crab-apple, sour grapes, 

3 Mill, millet. 


of the chylde in the Mothers bellye, all the thronges and 
paynes tomblynge in the forepart of the bottome of the 
belly, the woman stronge and mightie of nature, such as can 
wel and strongly helpe her self to the deliveraunce of the byrth. 
And agayne, evyl signes be those, when she sweteth colde 
sweate, and that her pulces beate and labour over sore, and that 
she her self in the labouring faint and sowne, these bee unluckie 
and mortall signes." 

The third chapter of this Book is, in some respects, the 
most important and the most interesting of the whole work, for 
it deals with " howe a woman with childe shal use her selfe, 
and what remedies be for them that have harde labour." If 
there should be any disease, swelling, or apostumation (abscess) 
about the uterus, vulva, or bladder (such as stone or strangury), 
then " in these cases it behoveth such thynges to be loked unto 
and cured before the time of laboure commeth, by the advise of 
some expert Surgion." Her diet x before labour will be different 
from that during labour. If there be constipation, she must 
use "suche thinges, the whiche may lenifie, mollifie, dissolve, 
and lose the belly : as apples fried with suger taken fastynge in 
the mornynge, and after that a draught of pure wyne alone, 
or elles tempred with the juyce of swete and very rype apples. 
Also to eate figges in the mornynge fasting, and at nyght, 
looseth 'well the bellye. If these profite not, Cassia fistula 
taken iii. or iv. drams one halfe hour before diner, shal loose 
the belly without parel." The woman also must refrain from 
taking constipating things (" hard egges," etc.), and it may be 
necessary for her to get a clyster, " but it must be very gentle 
and easye." An easy and temperate purgation (as by mercury) 
may be needed, "or elles a suppositar tempered with sope, 
larde, or the yolke of egges." If she be faint or sickly just 
before her labour, "then must ye comfort her with good 

1 Diet here means course of living and not simply the food or drink 


comfortable meate, drinke, holsome and noble electuaries." 
Various ointments and baths are to be used before labour: 
" Annointmentes wherewith ye may sople the privie place, 
be these. Hennes grese, Duckes grese, Goose grese, also 
oyle Olife, Linsede oyl, or oyl of Fenegreke, or the visco- 
site of holyoks." She is to bathe in water in which have been 
seethed "Malowes, Holyoke, Camomel, Mercury, Maiden- 
haire, Lyneseede, Fenegreke seede, and such other thynges 
which have vertue to mollifie and sople." If she be not able to 
take such baths, she must sponge herself with the water and 
apply ointments locally. Sweet fumes also are useful: "it 
shalbe also very profitable for her, to suffume the nether places 
with muske, Ambre, Gallia, Muscata, which put on embres, 
yelde a goody savoure, by the whiche the neather places open 
theymselfe, and drawe downwarde." She must also " exercyse 
the bodye in doing some thinge, styring, moving, goynge, or 
standinge, more then otherwise she was wont to doe." 

Hints are given as to what must be done when labour pains 
come on. " To withstand, defend, and to put away so neare as 
mai be the instant and present dolours. And as touchinge 
this poynt, it shalbe verye profytable for her, for the space of 
an houre to syt styll, then (rysynge agayne) to goe up and 
downe a payre of stayres, crying or reaching so loude as she 
can, so to styre her selfe." 

Here follows the oft-quoted passage about the "womans 
stoole " or " obstetric chair " which is represented in the Birth 
Figures. "Nowe when the woman perceaveth the Matrix or 
Mother to ware laxe or loose, and to be dissolved, and that the 
humours yssue foorth in great plentie, then shall it be mete 
for her to sit downe leaninge backwarde in maner upright. 
For the which purpose in some regions (as in Fraunce and 
Germany) the Midwyfes have stoles for the nonce, whiche 
beynge but lowe, and not hye from the grounde, be made so 
compasse wyse and cave or holowe in the middes, that that 


mai be receaved from underneth which is looked for, and the 
backe of the stole leaning backeward, receaveth the, back of 
the woman, the fashion of the which stole, is set in the begin- 
ning of the birth figures hereafter. And when the tyme of 
laboure is come, in the same stoole ought to be put many 
clothes or cloutes in the back of it, the which the Midwife 
may remove from one syde to another accordinge as necessitie 
shall require. The Midwyfe her selfe shall syt before the 
labourynge woman, and shall diligentlye observe and wayte, 
howe much, and after what meanes the chylde styreth it selfe, 
also shall with her handes fyrste annoynted with the oyle of 
Almondes, or the oyle of whyte Lyllies, rule and dyrecte every 
thyng as shall seme beste. Also the mydwife muste enstructe 
and comfort the partie, not only refreshing her with good 
meate and drink, but also with swete woordes, gevynge her 
good hope of a spedefull delyveraunce, encouraginge and 
enstomakinge her to pacyence and tolleraunce, byddynge her 
to holde in her breath so much as she may, also strekinge 
gentilly with her handes her bellye above the Navell, for 
that helpeth to depresse the birth downewarde." 

If the patient, however, be fat, the writer recommends 
that she " lye grovelynge," and if necessity require it " let not 
the midwife bee afrayde ne ashamed to handle the places, and 
to relax and loose the straites (for so muche as shal lye in 
her), for that shal helpe wel to the more expedite and quicke 
labour." She is warned, however, against interfering too soon 
" before the byrth come f orwarde," and she ought not to allow 
the patient to expend her strength before the proper time. 
When the bag of membranes appears, " then maye ye knowe 
that the labour is at hand." If the bag do not burst of its own 
accord, "it shalbe the Mydwyfes part and office, with the 
nayles easely and gen telly e to breake and rent it, or yf that 
may not conveniently be done, then rayse up betwene your 
fyngers a peece of it, and cut it with a payre of shieres, or a 


sharpe knyfe, but so that ye hurt not the byrth with the cut." 
If the membranes have ruptured or been ruptured too early, 
a dry labour results requiring the application of "oyle of 
why te Lyllyes or some of the greses spoken of before " to the 
parts; "but chiefely in these difficulties should profite the 
whyte of an egge together with the yolke powred into that 
same place : which shoulde cause it to be most slyppery and 
slydynge, and supplye the roome of the naturall humidities 
spent before." 

The birth of a child with a large head or of twins is to be 
assisted by the midwife, who is to " helpe all that she maye, 
with her hande fyrste annoynted with some oyle openying and 
enlargyng the waye that the issue maye be the freer." 

So far the writer has been dealing with the " natural byrth 
when that first proceadeth the head," as is represented in the 
first of the Birth Figures. He now describes in turn the various 
ways in which the infant or infants may present, and in what 
manner the midwife is to treat them. In the second of the 
Birth Figures a child is represented coming feet first (the 
attitude of the foetus is wrongly represented, as it is indeed in 
most of the figures), and in such circumstances the midwife is 
apparently directed to perform cephalic version ! Here, at any 
rate, are the directions : " Sometime it chaunced the child to 
come the legges and both armes and handes downwarde, close 
to the sydes fyrst foorth, as appeareth in the seconde of the 
byrth figures. In this case the Mydwyf e must do all her payne 
with tender handlynge and annoyntyng to receave foorth the 
chylde, the legges. beynge styll close together and the handes 
lykewyse remaynynge as appeareth in the seconde figure. 
Howbeit, it were farre better (yf it may be done by anye 
possible wayes or meanes) that the Mydwyfe shoulde tourne 
these legges commyng fyrst foorth, upwardes agayne by the 
bellywarde, so that the head myght descende downewarde by 
the backe parte of the wombe : for then naturally agayne and 


without peryl might it proceade and come forth as the 

In the third of the Birth Figures the foetus is represented 
as coming by the feet with the arms displaced upward along- 
side of the head. "This is the perylloust maner of byrth" ; 
and the direction is that the midwife must do what she may 
" to turne the byrth (yf it may be possible) to the first figure," 
but no directions are given as to the way in which this is to be 
done. If she cannot do this, she is directed to convert it into 
the second figure by bringing down the hands ; and " if this 
also wyll not bee, then receave the feete as they come foorth, 
and bynde them with some fayre linnen cloth, and so tenderly 
and very softly lose out the byrth tyll all be come foorth, 
and this is very jeoperdous labour." When one foot only 
presents {Birth Figure IY.) version by the postural method (" the 
labouring woman's head to be the lower part of her body") 
is to be followed ; but if it do not succeed, the midwife is to 
bring down the other foot. The fifth Birth Figure represents, 
rather crudely, a transverse presentation ; the sole direction 
for its management is : " then must the Mydwyfe do so, that it 
may be returned to his naturall fashion, and so to come foorth." 
The sixth and seventh cases call for no special comment. The 
eighth Birth Figure shows descent of one of the arms alongside 
of the head ; under these circumstances the midwife is told to 
thrust the birth in again, and if this fail she is to try postural 
treatment ; the same procedure is to be adopted in the ninth 
mode of presentation when both hands come down. The 
directions for the management of a breech case {Birth Figure X.) 
are surprising: "Then must the Mydwyfe with her handes 
returne it agayne, untyll such tyme that the birth be turned, 
the legges and feete forwarde." A shoulder presentation is 
shown in Birth Figure XII. (described erroneously in the 
text as XI.), and the direction is, " then must ye fayre and 
softly thrust it back agayne by the shulders, tyll suchetyme as 



the heade come forwarde." Twin cases are shown in the Birth 
Figures XIV., XV., and XVI. ; in the first are two heads, in 
the second two breeches, and the third is a head and a breech 
presentation. In the description appended to the last-named 
mode of labour there is the suggestion that the possibility of 
head-locking was not unknown to the writer. 

On the whole, it must be admitted that the management of 
labour as set forth in this chapter falls far behind modern 
practice, not to say theory. The notions regarding the attitude 
of the foetus in utero were erroneous, the distinctions between 
the various presentations were incomplete {e.g., face cases are 
not figured or named), and the management not infrequently 
consisted in interfering in the cases which we should now leave 
alone and in using ointments and posture under circumstances 
in which more radical methods would now be adopted. One 
cannot help wondering also how the midwives carried out the 
. instructions given to them ; certainly they were not burdened 
with details. 

The fourth chapter (wrongly described as the fifth in this 
edition of 1650) deals with " the remedies and medicines by the 
which the labour may be made more tollerable, easy, and 
without great payne." The posture of the patient, the tempera- 
ture of the lying-in room, the provocation of sneezing (" and 
that eyther with the powder of Meborus 1 or els of pepper"), 
and the use of ointments are all referred to. Of the oils, 
ointments, perfumes, washes, drinks, pills, and plasters mentioned 
in this chapter, we need mention two only. Here is a perfume : 
" Take yelowe brymstone, Myrre, Mader, Galbanum, Oppopona- 
cum, of eche lyke much, and tempre all those together, makynge 
of them pylles, and with those also ye maye make fume, to be 
receaved underneath." The chapter closes with the prescrip- 
tion of "a plaster to provoke the birth." Here it is: "Take 

1 Eleborus, Hellebore, White Hellebore ( Veratrum album), was used 
as a sternutatory. 


wylde Gowarde, 1 and seeth it in water, in the same water 
temper Myrre, the juyce of Rue, and Barlye meale so much as 
shalbe sufficient, stampe these thynges together, and make it 
plasterwyse, then laye it to the womans bellye betwene the 
Navyll and the nether parte. This plaster shall helpe mar- 

Chapter V. is concerned with "howe the secondine or 
seconde byrth shalbe forced to issue foorth, if it come not freely 
of his owne kynde." Various causes of the non-expulsion of 
the placenta and membranes are enumerated, such as lack 
of strength from prolonged labour, " entanglement " of the 
secondines within the uterus, and swelling of the parts. The 
dangers of placental retention are also named, and include 
" suffocation and chokinge of the Matrix " and putrefaction of 
the after-birth. " The seconde birth retayned and kept within 
will soone putrifie and rot : whereof wyll ensue yll noysom and 
pestiferous vapoures ascendinge to the heart, the braynes and 
the midriffe, through the which meanes the woman shalbe 
short wynded, faynte harted, often soundinge and lyinge with- 
out any maner of movynge or styrringe in the pulces : yea, and 
many tymes is playnely suffocated, strangled and dead of it." 
The remedies proposed for non-expulsion of the placenta were 
founded to some extent upon the causal conditions so far as 
these were understood. If weakness from long labour were 
the cause, then must the "labourer" be "recomforted and 
strengthed with good comfortable meates and drinkes, which 
maye enhart her, as broath made of the yolcke of egges, or with 
good olde wine, and good fat and tidie fleshe, or Byrdes, Hennes 
fleshe, Capons, Partrige, Pigins and such like." If the cause 
were contraction of the passages, then oils and ointments 
are recommended to " make the waye slypper, sople, and easy 
for it to proceade." Perfumes, also, and vapours are said to be 
efficacious. "But if the retencion of the secondine come by 
1 Gowarde, Wild Gourd, Colocynth. 


reason that it is entangled or fastened in some place of the 
Matrix, so that it wyll not resolve ne loose ; then make a fume 
underneath of Brimstone, Ivie leaves, and Cresses, or elles of 
Cresses fygges." There are some curious restrictions, of which 
the following is an instance: "Also of all odoriferous and 
sweete smellinge thinges, as Ambre, Muske, Frankencense, 
Gallia Miiscata, and confection, neare the which savoures and 
perfumes put on the embers muste be so closely receaved 
underneth, that no part of the smell do ascende to the nose 
of the woman. For to the nose shoulde the savoure of nothynge 
come, but onely of suche thinges, the which stinke or have 
abhominable smell, as Asafetida, Castorium, mans hayre or 
womens hayre burnt, Pecockes fethers burnt." " Item let her 
be provoked to sneese with the powder of Eleborus or Pepper 
put in the nose, holdinge her mouth and nose so close as 
maye be." 

The following directions for the removal of the after-birth 
are interesting: "And yf it bee so that any parte of the 
secondine do appeare, let the Mydwife receave it tenderly, 
losynge it out fayre and softly, least it breake, and if ye doubt 
that it wil breake, then let the Mydwife tye that parte of the 
whiche she hath handfast to the womans legge or fote, not 
very strayght, least it breake, nether very lax, least it slip in 
agayne, and then cause her to sneese. Nowe yf the secondine 
tarye or stycke, so that it come not quickly forewarde, then 
loose it a lyttle and a lyttle very tenderly, wrethinge it from 
one syde to another, tyll such time as it be gotten out, but ever 
beware of violent and hasty movynge of it, leaste that with 
the seconde byrth ye remove the Matrix also." The danger of 
inversion of the uterus is doubtless alluded to in this last 
passage. The chapter closes with directions for a fumigation 
and a plaster, and with the following somewhat despairing 
instruction : " If for al this the secondine come not forewarde, 
then leave it, and use no more medicines ne remedyes to that 


purpose, but let it alone, for within fewe days it wyll putrifie 
and corrupt, and dissolve into a watery substaunce, thick like 
bryne, or other fex myxed with water, and so yssue foorth. 
Howbeit in the meane whyle it wyll put the woman to great 
paine in the head, in the heart, and in the stomacke, as we 
touched before." 

The sixth chapter is a long one, dealing with such important 
matters as "howe many thinges chaunce to the women after 
theyr laboure, and how to avoyde, defende, or to remedye the 
same." Among the "many thinges" are "the fever or ague 
or swelling, or inflation of the bodye, other tumblynge in the 
belly, or elles commotion or settelinge out of order of the 
Mother or Matrix," and the cause of these is sometimes " lacke 
of due and sufficient purgation and clensynge of the flowres 
after the byrth, or els contrarywyse over muche flowinge of 
the same, whiche sore doth weaken the woman, also the great 
labour and styrrynge of the Matrix in the byrth." 

The " ague " we may shrewdly suspect was septic poisoning, 
" for that commeth of like cause by retention of the flowres." 
The patient is then to " drinke water in the whiche is decocte 
Barley beaten, or Cicer 1 and Barley together, or water in 
whiche be sodden Tamarindi, or whaye of mylke, and let her 
eate Cullis 2 made of a Cocke, and sweete Pomegarnates, for 
these thynges do provoke the flowres," etc. Various remedies, 
resembling those already referred to, are to be given in such 
conditions as swelling of the body, "frettinge and knawynge 
of the guttes," " paine in the privie partes," " outragious flux of 
flowres," "coming forth of the fundament gut," and the like. 
It is unnecessary to describe in detail the curious plans 
adopted and mixtures administered in these cases, one instance 
must serve for all: "To stynte and restrayne the outragious 
fluxe of flowres, it shalbe verye good to binde the amies 

1 Cicer, a chick-pea. 

2 Cullis, a strong broth, a beef -tea. 


strayght and strongly, and not the feete or handes, as some 
unwyse men doe teache, and then to set a ventose boxe, or 
cupping glasse with fyre (which is called borying) under the 
brestes without anye scarification." Here is one of the 
plasters: "Take of the bloud stone called Emathites, Bole 
armeniacke of eche halfe an ounce, Sanguis draconis, Licium, 
of eche twoo drammes, Karabe, otherwye named Ambre, the 
cuppes of Acornes, Cipres tree nuttes, flowres of Pomegranade, 
of eche one dram, of the scales of Iron one dram and a halfe, 
Turpintine and Pitch lyke quantitie, or so much as shalbe 
sufficient to make a softe and somewhat liquid plaster." 

The next chapter (the seventh) deals with " aborcementes 
or untymelye byrthes, and the causes of it, and by what 
remedies it may be defended, holpen, and eased." Many 
curious causes are enumerated, among which is "a disease 
called Tenasmus, the which is when hath ever greate desyre 
and luste to the stool, and yet can do nothynge." Other 
causes are coughing, bleeding at the nose, "to be let bloud," 
strong purgation, hunger, cold, heat, etc. "Therefore ought 
women with chylde to eschewe much bathyng or going to 
the hotte houses in theyr teming" (teeming). "Item, the 
intemperancie and mutation of the ayre and weather may be 
cause of aborcement," and after this statement there follows 
an interesting paragraph on meteorology in its relation to 
health, as it was then understood. "Dancing and leaping" 
are also named as possible causes, and so are " sodayne anger, 
feare, dread, sorowe, or some sodaine and unloked for joy." 

To the modern reader the signs of abortion enumerated by 
the writer of the Byrth of Manhynde will appear most astonish- 
ing and unconvincing ; among them he will find " a great ache 
in the inner part of the eies toward the braynes," redness of 
the face, " ventositie or wynde runnynge from one syde of the 
bodye to the other." kt the same time there is a reference, 
but a very brief one, to the really important sign of "greate 


paynes and dolours of the Matrix." The means of diagnosis 
given are hardly such as to justify the author's confident 
assertion : " thus have I sufficently declared evident sygnes, 
whereby may be provyded and foreseene the aborcement before 
it come." The methods of treatment are those which we now 
have come to look for from our author, — baths, fumigations, 
plasters, ointments, odours, and such like; but he gives the 
midwife one good piece of advice: "Howbeit, in all thys 
matter, let not to make some expert Phisition of youre counsaile, 
yf ye may have suche one : for because that manye such thinges 
come, and not all by one way or meane." 

The eighth chapter (wrongly named the ninth in the edition 
of 1560) is concerned with "dead byrthes, and by what sygnes 
or tokens it maye be knowen, and by what meanes it may also 
be expelled." The signs are twelve in number ; but they are 
not very convincing, as may be gathered when it is noted that 
the twelfth sign is, if the mother's "handes put into very warme 
water, and then laycle on the belly, and the childe steare not." 
There is evidence of sound knowledge, however, in the statement 
that " of all these sygnes nowe, the more that come togeather of 
theym at one tyme and in one person, the surer maye ye be 
that the byrth is dead." 

The prognosis, grave or favourable, in cases of dead-birth 
labours is set forth : " Whether the Mother shalbe in parell 
or no, by these thinges shall ye knowe. If the woman beynge 
in the laboure sowne or feare as though she were in a transe : 
yf her remembraunce fayle her, and she were feble and scante 
able to moue or styre herselfe, yf she (called with a loud voyce) 
canne aunswere nothinge at all, or elles verye lyttle, and that 
verye softely, as though her voyce began to fayle her : if she 
be invaded or taken among in the labouring with convulsion or 
shrinkelynge together : if she refuse or cannot brooke meat : yf 
her pulces beat every faste, the which signes when ye se in the 
woman labouringe, it is an evident token that she shal not lyve 


longe after her delyveraunce, wherefore commit the cure of her 
to the handes of almyghtie God." 

The treatment consists in getting ride of the " dead burthen " 
either by " medicines expulsy ve " or else by certain instruments 
made " for the nonce." Here, again, we find described a long 
list of fumigations, containing such things as the hoof or dung 
of an ass, the skin of an adder, "hawkes' dung" or "oxe gall," 
of suppositories or pessaries, of drinks (" yf the woman drynke 
the mylke of another woman, it will styre and expell the 
byrthe "), and of plasters. " But yf all these medicines profyt 
not, then must be used more severe and harde remedyes, with 
instrumentes : as hokes, tounges, and suche other thinges made 
for the nonce." From the wording of the directions it is 
evidently intended that the midwife herself shall fix the hooks 
into the eyes, or mouth, or shoulders, or ribs of the dead foetus 
and make traction, other women keeping the patient down. 
Arms and legs are to be cut off, if need be, and the head is to 
be opened with a sharp penknife if it be much swollen. Both 
the head and trunk may have to be broken up into pieces with 
" such instrumentes as the Chirurgions have readye and neces- 
sarye for suche purposes." 

The last paragraph of this chapter must be quoted entire : 
" But contrary to all this, yf it chaunce that the woman in her 
labour dye, and the chylde having lyf e in it : then shal it be 
meete to kepe open the womans mouth, and also the nether 
places ; so that the chylde may by that meanes both receave 
and also expell ayre and breath, which otherwyse myght be 
stopped, to the destruction of the chylde. And then to turne 
her on the lefte syde, and there to cut her open, and so to take 
out the chylde. They that be borne after this fashion are called 
Cesares, for because they be cutte out of theyr mothers belly : 
whereupon also the noble Komayne Cesar the fyrste toke his 
name." Assuredly the directions given here for a post-mortem 
Cesarean section are not too explicit ! 


Chapter IX. (by error called Chapter X. in the Kaynalde 
editions) has no representative in the 1540 edition or in 
Kosslin's De Partu Hominis, and we must, therefore, ascribe it 
to Kaynalde. It contains a list of medicines, ointments, and 
plasters (" suche as hath ben wel experimented and practysed "), 
to be used to quicken delivery and to expel the after-birth. The 
reader is, by this time, able to foretell pretty accurately what 
kind of drugs will be in these medicines, and I need only refer 
to certain " trochiskes " upon which the writer evidently places 
much reliance. " Item, of Saffron dried by the fyre tyl it be 
blackyshe, of Cassia lignea, fine Keubarbe, Savine dryed, 
Myrreh, of eche of these seven scruples, of pure muske, xvi. 
graynes, every of these simples exquisitely by them selves 
powdred, and then perfectlye myxed in one, with vi. or vii. 
droppes of Malvesey, temper the whole mase into lyttle 
roundels or trochiskes, eche waying a dram. And in tyme of 
neede at the womans labour, geve her hardly the wayght of vi. 
d. of these trochiskes beaten into fine powder, with foure 
sponefulles of Isope water, and other foure of good wine secke." 
The chapter closes with a paragraph (to which I have referred 
in my previous article as the " Bucklersbery paragraph") telling 
where the " trochiskes " are to be obtained. 

Such are the contents of the Second Book as they appear in 
the 1560 edition. There are slight verbal differences in some 
of the other editions, and these specially affect the " Bucklersbery 
paragraph." More distinct variations separate the 1540 or 
Jonas editions from that of 1560 and from the rest. The 
whole of the ninth chapter (erroneously called the tenth) is 
absent from the 1540 edition ; there is a difference in the 
wording of the commendation of the "plaster to provoke the 
birth," Jonas being less certain about its efficacy than Kaynalde, 
and throughout the whole book Jonas is more in the habit of 
introducing such phrases as "Avicenna saith" or "Hippocrates 
writeth " than Kaynalde (e.g. in Chapter VIIL). The differences 


are simply due to the fact that Jonas translated Kosslin's book 
literally, whereas Eaynalde gave a more free rendering and 
supplemented the work here and there. For this reason, also, 
it comes about that the Second Book of the Eaynalde editions is 
part of the First Book of the Jonas edition, for it really 
represents Chapters II. to IX. of Kosslin's De Partu Hominis. 
Jonas's First Book corresponds to Chapters I. to XL of Kosslin. 

The "Byrthe Fygures." 

The "Byrthe Fygures," including the "Woman's Stoole," 
belong to the Second Book of the 1560 and of the other 
Eaynalde editions. They are all taken from Kosslin's De 
Partu Hominis, but they are not placed in the same order. 
Further, there is one in Kosslin's book which does not appear in 
the 1560 edition (or, so far as I know, in any of the Kaynalde 
editions); this has been reproduced in Fig. V. It will be 
noted that in some respects it more nearly represents the true 
attitude of the foetus in utero than any of the others. I have 
reproduced five of the Kosslin figures (including the " Stoole ") 
which have their representatives in the Kaynalde editions 
(Figs. YI.-X.), so that the reader may compare them with the 
same pictures as they appear in the English translation (see my 
previous article, Plates VIII., IX., X., and XL). I have already 
(loo. cit.) referred to the great interest which the " Byrth Fygures " 
of the Byrth of Manhynde have excited as being the earliest, or 
almost the earliest, specimens of English copperplates. 

The Third Book. 

The Third Book of the 1560 edition of the Byrth of Man- 
kynde consists of three chapters, the third being a very long 
one. It is devoted to the care of the new-born infant, and to 
its " dy verse diseases and inf yrmities " : the first chapter speaks 


of the umbilical cord and its management, the second of the 
nurse and her milk, and the third of the maladies of infants 
and the remedies required for them. "Then after that the 
Infant is once come to lyght, by and by the Navyll muste be 
cut three fyngers breadth from the belly, and so knit up, and 
let be strued on the head of that remayneth, of the powder of 
Bole armeniacke, and Sanguis draconis, Sarcocolla, Myrrhe, and 
Cummin, of eche lyke muche beaten to pouder, then upon that 
bynd a peece of woll, dypped in oyle Olive, that the powder 
fall not of. Some use fyrst to knyt the Navyl, and after to cut 
it so much, as is before rehearsed." The writer mentions the 
belief that the length of the stump of the cord will determine 
the length of the " chyldes tonge," if it be a man-child. He 
also refers to Avicenna's statement that the wrinkles on the 
cord betoken the number of future pregnancies the patient is to 
have and the intervals of time (long or short) between them ; 
" but these sayinges be nether in the G-ospell of the day, ne of 
the night." 

The child's body is to be rubbed with oil of acorns. " After 
this annoyntyng, washe the Infante with warme water, and 
with your fynger (the nayle beyng pared) open the chyldes 
nosethrilles, and purge them of the fylthiness." After the fall 
of the cord (" whiche commonlye chaunceth after the thyrde or 
fourth daye") the cicatrix is to be dusted with "ashes of a 
Calfes hove burnte, or of Snayle shelles, or of the powder of 
lead, called red lead, tempered with wyne." The proper 
swaddling of the child is then described, so that its limbs may 
grow straight ("as it is in yonge and tender impes, plantes, 
and twygges ") ; the eyes should be frequently washed, and it 
should sleep in its cradle in such a place that neither the 
beames of the Sunne by day, neither of the Moone by nyght 
come on the Infant." It is to be washed two or three times a 
day; and, after that, to put a drop or two of water into its 
nostrils is " very good for the eye syght." 


" It shalbe beste that the mother give her chylde sucke her 
selfe, for the mothers mylke is more convenient and agreable to 
the infant, than any other womans, and more doth it nouryshe 
it, for because that in the mothers belly it was wont to the same, 
and fed with it, and therefore also it doth more desyrouslye 
covet the same, as that with the which it is best acquainted." 
Apparently the nursings are not to be frequent : " As Avicenna 
writeth it shalbe sufficient to give sucke twyse or thryse in a 
daye." If the mother be unable to suckle her child, then 
a " holsome Nourse " is to be sought out ; five or six essential 
qualities are enumerated which she must possess, and a method 
of testing the milk upon the thumb nail is described. There 
is a long list of remedies which are said to increase the quantity 
of the milk. Two instances must serve : " Item, to eate shepes 
brestes, and the mylke of them is good " ; " Item, take two 
drams of Crystall beaten into fyne powder, and devyde that in 
f oure equal partes : one of these partes geve unto the Nourse, 
the space of foure dayes to drynke, with broth made eyther of 
Cicer, 1 or elles of peason." 2 The child is not to be put to the 
mother's breast for a day or two after birth, " because that the 
creme (as they cal it) straight after the byrth, the first day in 
al women doeth thicken and congile." This, it need hardly be 
said, is not the rule of procedure at the present time. Weaning 
should take place at the end of the year, and it is not to be 
carried out suddenly but gradually; the infant is not to be 
given "lyttle pylles of bread and sugar to eate" until it be 
able to " eate all maner of meate." 

The third chapter of this book is taken up, as has been said, 
with the diseases of infants and their treatment. It is of interest 
rather to the pediatric physician than to the obstetrician ; but 
I may enumerate some of the subjects dealt with : " loosenesse 
of the bellye, cough and distillation, 3 short winde, wheales on 

1 Cicer, chick-pea. 2 Peason, pease. 

3 Distillation, a catarrh or defluxion of rheum. 


the tounge, apostumation and runninge of the eares, bolnynge 1 
of the eyes, often sneesinge, whelkes in the body, swelling of 
the coddes, 2 unslepinesse, yeringe or the hyckate, 3 terrible 
dreames, wormes in the belly, the fallynge syckenes, the palsey, 
and gogle eyes 4 or loking squint." It is unnecessary to quote 
the means recommended for the treatment of these various 
maladies, but the following prescription for the falling 
sickness (epilepsy) may be given by way of sample: "Item, 
to hange Viscum quersinum, 5 which is gathered in Marche 
the moone decreasynge, about the Chyldes necke, is very 

The Third Book as it appears in the 1560 edition differs 
little from what it is in the other Eaynalde issues, earlier or 
later. I have found a few verbal differences between it and the 
1552 edition (e.g., in the paragraph on " Unsleppynesse "), and 
in the 1654 edition there is a new chapter (placed quite at the 
end of the work) amplifying what has been said about the 
nursing of children and " how' to choose a good nurse." The 
1540 edition differs more markedly: the chapter on "unsleepi- 
ness" is shorter, that on swelling of the coddes is not the 
same; there are two additional short paragraphs (the one 
" against the mother," and the other of short breath, hoarseness, 
or whistling in the throat), and there is an additional sentence 
on infantile constipation. 

The Third Book of the Eaynalde editions corresponds to 
Chapters X. and XI. of the First Book and to the whole of the 
Second Book of the 1540 or Jonas edition. It forms, also, the 
tenth, eleventh, and twelfth chapters of Be Tartu Hominis, 
from p. 61 to the end (in the edition of 1538). 

1 Bolnynge, swelling or a tumour. 

2 Coddes, testicles. 

3 Hyckate or yexing, the hiccup. 

4 Gogle eyes, staring eyes or squint eyes. 

,r> Viscum quersinum, mistletoe of the oak. 


The Fourth Book. 

The Fourth Book of the 1560 as well as of the other 
Kaynalde editions consists of six chapters ; these are not found 
in Kosslin's De Partu Hominis, but five of them are present in 
the 1540 or Jonas edition of the Byrth of Mankynde, so that 
only one (the sixth) chapter is peculiar to the Baynalde 
editions. The Fourth Book of the 1545 and of all later 
editions corresponds to the Third Book of the 1540 or first 

An idea of the subjects dealt with in the Fourth Book can 
best be obtained from the short summary contained in the 
first chapter. I quote (in this instance) from the 1552 edition : 
" Here in this fourth Boke (by ye leave of God) shal brefely be 
declared soch thinges which may farther or hinder the con- 
ception of man, whych as it may be by dyvers meanes letted 
and hyndered, so also by many other wayes it may be farthered 
and amended. Also to knowe by certayne sygnes and tokens 
whether the woman be conceaved or no, and whether the con- 
ception be male or female, and finally certayne remedies and 
medicines to farther and help conception : and there after we 
wyll (accordynge to our promyse in the prologue) set forth 
certayne bellyfying receptes, and so make an ende of this hole 

The second chapter gives the author's views as to the 
necessary conditions for the growing of corn between which 
and human generation he draws a parallel : " Ther be in al maner 
of generation thre principal partes concurrent to the same : ye 
sower, the sede so wen, and the receptacle or place receaving 
and contayninge the seede." The third chapter applies this 
principle to the consideration of the causes of sterility, and 
enumerates faults in the mother receiving the seed, faults in 
the sower, and faults in the seed itself. The mother's womb 


is fancifully compared to the ground ; it may be too hot, too 
cold, too moist, or too dense. The following paragraph may be 
quoted to show how the author persuades himself that coldness 
of the matrix is a cause of sterility : " Tor yf corne be sowen in 
over cold places, soch as be in the partes of a countrey, called 
Sithia, and in certayne places of Almayne, or in soch places 
where is contynual snow or frost, or wher the sunne doth not 
shyne: in these places the sede or grayn sowen, wyl never 
come to profe, nor fructyfy, but through the vehement coldnesse 
of the place in the which it is conceaved, the lyfe and quickenes 
of the grayne is utterlye destroyed and adnihilat." The man's 
seed also may be defective as to heat, cold, thickness, etc. 
Even more fanciful is the fourth chapter, which pretends to 
give ways of finding out whether sterility is due to defect in 
the woman or the man. "Let eche of theim take of wheate 
and barleye cornes, and of beanes of ech vii., the which they 
shal sufFre to be steped in theyre severall uryne : the space of 
xxiiii. hourses : then take ii. pottes, soch as they set gylyflowres 
in : fyl them wyth good earth : and in the one let be set the 
wheat, barlye, and beanes, styped (steeped) in the mans water, 
and in the other the wheat, barly, and beanes styped in the 
womans water: and everye morninge the space of viii. or x. 
dayes, let eche of them with theyr proper urine water the sayd 
sedes sowen in the foresayd pottes and mark whose pot doth 
prove, and the sedes therein contayned doth grow, in ye partye 
is not the lack of conception, and se yf ther come no other 
water or rayne on the pottes." This marvellous test ends with 
the wise remark, "but trust not moch this farfet 1 experiment." 
Other tokens are given, taken from the works of Hippocrates 
(which are often quoted in this Book), but the writer warns the 
reader that "these tokens, although they have a certain reason 
and apparence, yet be they not alwayes unfallyble, but onely 
lycklye" The signs of pregnancy are described (menstrual 

1 Farfet, far-fetched. 


suppression, changes in the breasts, " longings," and thickness 
of the urine), and directions are given to enable the midwife to 
tell whether the unborn child is male or female. 

The fifth chapter contains various prescriptions supposed to 
be efficacious in curing sterility, but they call for little comment 
and no commendation, being founded upon the etiological 
theory of lack of heat or cold or moisture in the woman or in 
her uterus. 

The sixth and last chapter of the Fourth Book may be called 
the " cosmetic " one, for it deals with what the writer (Eaynalde) 
calls " dy vers bellyf ying " medicines and remedies. It is pro- 
posed to show how certain blemishes (" as it were weedes of the 
body") are to be removed, such as "dandraffe" of the head, 
" hayre in places where it is unsemelye," " frekens or other 
spottes in the face," warts, and "pymples." There are also 
instructions how to keep and preserve the teeth clean, and how 
to prevent " stynckynge breath " and " ranke savour of the 
armeholes." I need only quote the last paragraph: "Item, 
auctors do wryte the ye rootes of artichauts (ye pithe pyked 
oute) soden in whyte wyne and so dronke, doth dense the 
stenche of the arme holes and other partes of the body by the 
wyne : for (as Gallen also doeth testyfye) he provoketh copy 
and plenty of stinkynge and unsavery uryne, from all partes of 
the body, the whych propertye it hath by specyall gyft and not 
only by his hote qualyte. And thus here I make an ende of 
thys fourth and last boke." 

The sixth chapter is wanting in the Jonas edition of 1540, 
but is to be found in all the Eaynalde editions from that of 
1545 onwards. 

No part of the Fourth Book is to be found in either of the 
editions of Eosslin's Be Partu Hominis, and we must conclude 
that Chapters I. to V. were written by Jonas, Eaynalde adding 
the sixth. Both Eaynalde and Jonas seem to have gone to 
Hippocrates for their facts (if facts they can be called), or! to 


some work which quotes Hippocrates. The latter is the more 
probable explanation of the source of the Fourth Book. 

Ehodion's "De Partu Hominis." 

As we have seen, Jonas translated Eosslin's or Ehodion's 
De Partu Hominis into English, adding a few chapters thereto, 
and Eaynalde revised the translation and added new material. 
But who was Eosslin and what was the history of his work ? 

Eucharius Eosslin, Eoslin, or Ehodian was a medical man 

practising first in "Worms and then in Frankfort-on-Main. 

The date of his birth is unknown, and for his death year two 

dates have been given — 1526 and 1553. The earlier of the two 

is most probably the correct one, the later date being that of 

the death of his son. He published his work entitled Der 

Swangern Frawen und Hebammen Rosegarten (by Imperial 

Privilege) in 1513, and so gave to the world the first separate 

work on midwifery. It was dedicated to Catherine, Princess 

of Saxony and Duchess of Brunswick and Luneburg; and it 

was a compilation from the works of Hippocrates, Galen, 

Avicenna, Albertus Magnus, Aetius, Gordon, and Savonarola. 

The earliest edition (that of 1513) had the same Birth Figures 

as were found in Jonas and Eaynalde ; they were printed from 

woodblocks. The work was divided into twelve chapters 

corresponding to the First and Second Books of the Jonas 

edition of the Byrth of Mankynde,. and (speaking generally) to 

the Second and Third Books of the Eaynalde editions of the 

same work. Several German editions of the Rosegarten 

appeared (in 1522, 1529, 1571); then it was translated into 

Latin, and, as De Partu Hominis, editions were brought out in 

1532, 1535, 1536, 1537, 1538, 1551, 1554, 1556, and 1563 ; 

Dutch translations, under the title of Den Rosegaert van den 

bevruchten Vrouwen, came out in 1540, 1555, 1670, 1685, 1701, 

and 1730; and there were French versions in 1536, 1540, 




1563, and 1577. The English translations we have already 

In order that the reader may judge of the accuracy of the 
Jonas and Kaynalde rendering of Ehodion's work, I place 
here in parallel columns the Latin and the English of two 
passages, one referring to the " Woman's Stoole " and the other 
to Cesarean section : — 

From Ehodion's "De Partu 

From Raynalde's "Byrth of 

" Ad quam quidem rem, in qui- 
busdam regionibus ut in Gallia et 
Germania superiori, obstetrices 
peculiaria sedilia habent, quae et 
ab humo non non alte distant, et 
excavata ita sunt, ut facile, quae 
debent, transmittant, et reclinan- 
tem tergo accipiant : quarum forma, 
fere est talis, qualem hie adpinxi- 

" At vero si diverso modo pariens 
emoriatur inter enitendum, id quod 
signis, quae morientes de se prae- 
bent, facile deprehendi potest, et 
partus in utero superstes, spem 
vitae ostendat, principio convenit 
morientis os, et infra genitalia cum 
matrice aperta et reclusa servare, 
quo per ea et vitalem spiritum 
partus capere, et anhelitum recipro- 
care possit, id quod mulieres medio- 
criter peritae satis norunt. Deinde 
reclinatae latus sinistrum recto 
vulnere novacula incidi atque 

" For the which purpose in some 
regions (as in Fraunce and Ger- 
many) the Midwyfes have stoles for 
the nonce, whiche beynge but lowe, 
and not hye -from the grounde, be 
made so compasse wyse and cave 
or holowe in the middes, that that 
mai be receaved from underneth 
which is looked for, and the backe 
of the stole leaning backeward, 
receaveth the back of the woman, 
the fashion of the which stole, is 
set in the beginning of the birth 
figures hereafter." 

" But contrary to all this, yf it 
chance that the woman in her 
labour dye, and the chylde havyng 
lyfe in it : then shal it be meete 
to kepe open the womans mouth, 
and also the nether places ; so that 
the chylde may by that means 
both receave and also expell ayre 
and breath, which otherwyse 
myght be stopped, to the destruc- 
tion of the chylde. And then to 
turne her on the lefte syde, and 
there to cut her open, and so to 
take out the chylde. They that 


aperiri (nam dexterum latus non be borne after this fashion are 
ita liberum, propter hepar quod called Cesares, for because they be 
in eo situm habet, ingressum in- cutte out of theyr mothers belly : 
cidenti praebet) et inde partus whereupon also the noble Romayne 
inserta manu per vulnus eximi Cesar the fyrste toke his name." 
atque educi debet. Quo pacto qui 
nascuntur, cesares dici solent, ut 
etiam Romae ille a quo primo 
cesarum familia nomen adepta 
fuit, primusque caesar, eo quod 
caesa est matre natus, appellatus, 

It will be seen that the translation is not strictly literal, 
neither is it exact : for instance, the reason why the abdomen 
(in Cesarean section) is to be opened on the left side rather than 
on the right is given in the Latin version but does not appear 
in the English. Possibly some divergences may be explained 
on the supposition that Jonas and Raynalde used editions of 
Be Partu Hominis which I have not been able to see. 

I have now concluded my survey of this remarkable book — 
The Byrth of Mankynde — both as regards its contents and in 
respect to its authors and editions. Although its precepts may 
bring a smile to the face of the obstetrician of the present day 
and merit his contempt, yet it was the most potent factor in 
establishing the popular customs which cluster round the 
practice of midwifery in these Islands, customs which can be 
traced and recognised even now. 

Addenda et Corrigenda. 

Since I wrote my article on the Author and Editions of the 
Byrlh of Mankynde I have been informed of several other copies 
of some of the editions, and have been led to alter some of the 
statements made. For instance, I am doubtful of the existence 
of an edition of 1676. Dr C. Napean Longridge, to whom I am 


greatly indebted for a series of researches made for me in the 
British Museum, finds that the so-called copy of 1676 named in 
the catalogue of the Museum is really that of 1626. I have, 
therefore, removed this edition from the list. 

I have now had an opportunity of examining a copy of the 
1604 edition. It belongs to Prof. H. E. Spencer, to whose kind- 
ness I am indebted for the privilege of inspecting it. It is very 
similar in all respects to the edition of 1598. The ornamental 
title page is exactly the same, with the exception of a few 
differences in the typography of the title. At the foot of the 
inscription is, " Imprinted at London for Thomas Adams," 
instead of, "Imprinted at London by Eicharde Watkins," 
which appears in the 1598 edition. The colophon reads, 
"Imprinted at London for Thomas Adams, 1604." There 
are 204 pages in this edition, and three preliminary leaves ; 
the plates are the same, although two plates of the " Byrthe 
Fygures" happen to be missing in the copy which I am 
describing; and .the type is black letter mostly. It would 
seem, therefore, as if Watkins, the printer of the 1598 edition, 
had assigned the blocks as well as the license for printing the 
Byrth of Mankynde to Thomas Adams. 

I must correct the statement made by me on p. 243 of 
my former article (loc. cit.) about the ninth figure of the 
Anatomical Plates. It does not make its first appearance in 
the edition of 1560 ; it was present (as Figure 5) in the 1545 
and 1552 editions. The altering of the order of description of 
the figures in the 1560 issue had misled me. 

Here follows the revised list of the editions. I may take 
this opportunity of thanking Dr E. Wilson Gibson, of Orton, 
Tebay, Westmorland, for kindly giving me a perfect copy of 
the 1654 edition. 


Summary of the Editions of the " Byrth of Marikynde." 

Edition of 1540. Jonas's Translation of Eosslin. British 

Edition of 1545. Eaynalde's Translation. British Museum ; 

Royal College of Physicians, London ; Hunterian Library, 

University, Glasgow. 
Edition of 1552. Eaynalde's Translation. Eoyal College of 

Physicians, Edinburgh; London Obstetrical Society; Dr 

W. Blair Bell, Liverpool. 
Edition of 1560. Eaynalde's Translation. Eoyal College of 

Surgeons, London; Dr J. W. Ballantyne, Edinburgh; 

University of Aberdeen. 
Edition of 1565. Eaynalde's Translation. British Museum; 

University of Edinburgh; Eoyal College of Surgeons of 

London; Washington Library; Hunterian Library, 

University, Glasgow. 
Edition of 1564 (?). Eaynalde's Translation. British Museum ; 

University of Glasgow; Eoyal College of Physicians, 

London ; Dr J. F. Payne, London. 
Edition of 1593 (?). Eaynalde's Translation. Eadford Library, 

Edition of 1598. Eaynalde's Translation. British Museum; 

Eoyal Medico - Chirurgical Society of London ; Dr 

C. E. Underhill; Washington Library; Hunterian 

Library, University, Glasgow; Medical Institution, Liver- 
Edition of 1604. Eaynalde's Translation. British Museum; 

Washington Library ; Dr H. E. Spencer, London. 
Edition of 1613. Eaynalde's Translation. Eoyal College of 

Surgeons of London (2 copies). 
Edition of 1626. Eaynalde's Translation. British Museum; 

University of Edinburgh; London Obstetrical Society; 

Faculty of Physicians and Surgeons of Glasgow. 


Edition of 1634. Kaynalde's Translation. British Museum; 
Koyal College of Physicians, London; London Obstetrical 
Society ; Washington Library. 

Edition of 1654. Kaynalde's Translation. British Museum; 
Washington Library ; Dr W. L. Eeid, Glasgow ; Uni- 
versity of Aberdeen ; Dr J. W. Ballantyne, Edinburgh. 


Abortion, case of repeated, due to 
syphilis; treatment by potassium 
iodide; birth of child with con- 
genital goitre (Watson), 204. 

Albuminuria, acute, caused by pres- 
sure of tumour on both ureters 
(Porter). 75. 


Ballantyne, Dr J. W., gives inaugural 
address, 3 ; reads paper, 236 ; shows 
specimens, 120, 191, 221 • on Dr 
Porter's paper, 81 ; on Dr Eliz. 
Macdonald's paper, 116; on Dr 
Haultain's paper, 131 ; on Sir 
Halliday Croom's paper, 158; on 
Professor Jardine's paper, 1 83 ; on 
Dr Campbell's paper, 189; on Dr 
Brewis's paper, 203 ; on Dr Watson's 
paper, 218; on Professor Kynoch's 
paper, 234. 

Barbour, Dr Freeland, moves vote of 
thanks, 2; reads paper, 136 ; shows 
specimens, 121 ; on Dr Lackie's 
paper, 33 ; on Dr Haultain's paper, 
132 ; on Sir Halliday Croom's paper, 
158; on Professor Kynoch's paper, 

Bilateral ovarian dermoid tumours 
complicating pregnancy (Campbell), 

Brewis, Dr N. T., reads papers, 49, 
191 ; shows specimens, 41, 140, 189 ; 


on Dr Ferguson's paper, 65 ; on Dr 
Haultain's paper, 133; on Sir 
Halliday Croom's paper, 1 59 ; replies 
to discussion, 57, 203. 
"Byrth of Mankynde"; its contents 
(Ballantyne), 236. 

Cesarean section for contracted pelvis, 
series of five cases of (Kynoch), 221. 

Campbell, Dr Malcolm, reads paper, 
184; replies to discussion, 189. 

Cervical fibroids removed by ab- 
dominal hysterectomy, a clinical 
and anatomical study of thirty 
cases of (Haultain), 121. 

Church, Dr, on Dr Lackie's paper, 37 ; 
on Sir Halliday Croom's paper, 162. 

Croom, Professor Sir Halliday, reads 
paper, 143; replies to discussion, 


Dermoid tumours, bilateral ovarian 

(Campbell), 184. 
Dewar, Dr, on Dr Lackie's paper, 35. 


Epilepsy and the status epilepticus in 
connection with pregnancy and 
labour (Jardine), 165. 



Exophthalmic goitre in its relation to 
Obstetrics and Gynaecology (Groom), 

Fellows, election of, Ordinary, 2, 41, 
74, 120, 163 j Honorary, 220. 

Ferguson, Dr Haig, reads paper, 57 ; 
shows specimens, 45, 142, 163, 190; 
on Dr Lackie's paper, 34 ; on Dr 
Leary's paper, 74; on Professor 
Jardine's paper, 182; on Dr Wat- 
son's paper, 217; replies to discus- 
sion, 66. 

Fibroid tumours, complicating preg- 
nancy, treated by hysterectomy 
(Brewis), 49. 

Fibroid tumours in pregnancy, hys- 
terectomy for (Barbour), 136 

Fordyce, Dr W., shows specimens, 164. 

Future of Obstetrics, inaugural 
address on the (Ballantyne), 3. 


Goitre, congenital, birth of child with, 
in case of repeated abortion, treated 
by potassium iodide (Watson), 204. 

Goitre, exophthalmic, in its relation 
to Obstetrics and Gynaecology 
(Croom), 143. 

Haultain, Dr, reads paper, 121 ; shows 
specimens, 48, 74, 164; on Dr 
Porter's paper, 81 ; on Dr Eliz. 
Macdonald's paper, 117; on Pro- 
fessor Jardine's paper, 180; on Dr 
Campbell's paper, 188. 

Intractable uterine haemorrhage and 
arteriosclerosis of uterine vessels 
(Eliz. Macdonald), 83. 

Jardine, Professor, reads paper, 165; 
replies to discussion, 183, 

Kerr, Dr Munro, on Professor Kynoch's 
paper, 230. 

Kynoch, Professor, reads paper, 221 ; 
shows specimens, 220 ; on Dr 
Porter's paper, 82 ; replies to dis- 
cussion, 235. 

Lackie, Dr Lamond, reads paper, 28 ; 
on Dr Brewis's paper, 56 ; on Dr 
Leary's paper, 73 ; on Professor 
Kynoch's paper, 234 ; replies to 
discussion, 40. 

Leary, Dr Garnet, reads paper, 67. 


Macdonald, Dr Eliz., reads paper, 83 ; 
replies to discussion, 119. 


Nicholson, Dr Oliphant, on Dr 
Lackie's paper, 37 ; on Sir Halliday 
Croom's paper, 160 ; on Dr Watsons 
paper, 214. 


Occipito-posterior cases, the manage- 
ment of some difficult (Lackie), 28. 
Office-bearers, election of, 2. 

Paterson, Dr Keppie, on Dr Brewis's 
paper, 57 ; on Dr Leary's paper, 72 ; 
on Dr Watson's paper, 216. 

Porter, Dr Fred., reads paper, 75 ; on 
Dr Ferguson's paper, 66; on Dr 
Eliz. Macdonald's paper, 119; on 
Professor Jardine's paper, 183; 
replies to discussion, 82. 

Prognosis of pregnancy in patients 
with one kidney, on the ; with 
notes of an unusually complicated 
case of labour after nephrectomy 
(Haig Ferguson), 57, 



Puerperal septicaemia, successful treat- 
ment of, by antistreptococcic serum 
(Leary), 67. 


Kitchie, Dr James, moves vote of 
thanks, 34 -shows specimens, 48; 
on Dr Lackie's paper, 34 ; on Dr 
Brewis's paper, 56; on Dr Fergu- 
son's paper, 66 ; on Dr Porter's 
paper, 82 ; on Dr Eliz. Macdonald's 
paper, 1 1 8 ; on Sir Halliday Croom's 
paper, 159 ; on Dr Watson's paper, 
214 ; on Professor Kynoch's paper, 

Specimens, exhibition of, 41, 74, 120, 
140, 163, 189, 220. 

Simpson, Dr Barbour, shows medal, 


Treasurer, annual statement of, 1. 

Vaginal Caesarean section, six cases 
of (Brewis), 191. 


Watson, Dr B. P., reads paper, 204 
on Dr Eliz. Macdonald's paper, 119 
on Sir Halliday Croom's paper, 162 
replies to discussion, 219. 






": m 





v. 32 

Edinburgh Obstetrical Society